MEDICARE: CAROL ELLEN DAFESH 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	44108	CA

General Provider Information

NPI Number	:	1154832285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL ELLEN DAFESH LMFT

Provider Business Mailing Address
First Line	:	PO BOX 171
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90267-0171
Country	:	US
Telephone Number	:	310-741-2231
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 PACIFIC COAST HWY STE 104
Second Line	:
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-2734
Country	:	US
Telephone Number	:	310-741-2231
Fax Number	:

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

Provider Enumeration Date	:	10/16/2017
Last Update Date	:	12/14/2017

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