MEDICARE: INTEGRATIVE PSYCHOTHERAPY GROUP, A MARRIAGE AND FAMILY THERAPY CORP

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1184238875
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATIVE PSYCHOTHERAPY GROUP, A MARRIAGE AND FAMILY THERAPY CORP

Provider Business Mailing Address
First Line	:	311 N ROBERTSON BLVD STE 718
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90211-1705
Country	:	US
Telephone Number	:	310-461-4148
Fax Number	:

Provider Business Practice Location Address
First Line	:	311 N ROBERTSON BLVD STE 718
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90211-1705
Country	:	US
Telephone Number	:	310-461-4148
Fax Number	:

Authorized Official
Title or Position	:	CEO & PRESIDENT
Name	:	MR. LEOR RAM
Credential	:	M.A., LMFT, LPCC
Telephone Number	:	310-461-4148

Provider Enumeration Date	:	09/01/2020
Last Update Date	:	09/01/2020

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