MEDICARE: DR. JUSTIN BRET AYRES LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC42200	CA

General Provider Information

NPI Number	:	1083896013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUSTIN BRET AYRES LMFT

Provider Business Mailing Address
First Line	:	461 W 6TH ST
Second Line	:	SUITE 204
City	:	SAN PEDRO
State	:	CA
Zip	:	90731-2694
Country	:	US
Telephone Number	:	310-435-1246
Fax Number	:	310-833-5672

Provider Business Practice Location Address
First Line	:	461 W 6TH ST
Second Line	:	SUITE 204
City	:	SAN PEDRO
State	:	CA
Zip	:	90731-2694
Country	:	US
Telephone Number	:	310-435-1246
Fax Number	:	310-833-5672

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2007
Last Update Date	:	11/29/2010

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