MEDICARE: THE HOLLYWOOD THERAPIST

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	251S00000X	Community/Behavioral Health Agency	54004	CA

General Provider Information

NPI Number	:	1124493184
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE HOLLYWOOD THERAPIST

Provider Business Mailing Address
First Line	:	7104 FRANKLIN AVE APT 12
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90046-3023
Country	:	US
Telephone Number	:	619-309-8291
Fax Number	:

Provider Business Practice Location Address
First Line	:	7104 FRANKLIN AVE APT 12
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90046-3023
Country	:	US
Telephone Number	:	619-309-8291
Fax Number	:

Authorized Official
Title or Position	:	LICENSED MARRIAGE FAMILY THERAPIST
Name	:	MR. JESSE HUGH HAUCK
Credential	:	LMFT
Telephone Number	:	619-309-8291

Provider Enumeration Date	:	12/02/2015
Last Update Date	:	12/02/2015

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Directions to “THE HOLLYWOOD THERAPIST ” Practice Location

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