MEDICARE: KENNETH SIMON RIBOTSKY 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	118486	CA

General Provider Information

NPI Number	:	1124648662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH SIMON RIBOTSKY LMFT

Provider Business Mailing Address
First Line	:	668 N COAST HWY # 224
Second Line	:
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-1513
Country	:	US
Telephone Number	:	949-706-4248
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 DOVE ST STE 100
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-2410
Country	:	US
Telephone Number	:	949-706-4248
Fax Number	:

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

Provider Enumeration Date	:	04/24/2020
Last Update Date	:	04/24/2020

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