MEDICARE: ADELE HOUSE MFT

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	46858	CA

General Provider Information

NPI Number	:	1255548962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADELE HOUSE MFT

Provider Business Mailing Address
First Line	:	12400 VENTURA BLVD
Second Line	:	#114
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-2406
Country	:	US
Telephone Number	:	310-266-7462
Fax Number	:

Provider Business Practice Location Address
First Line	:	12400 VENTURA BLVD
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-2406
Country	:	US
Telephone Number	:	310-266-7462
Fax Number	:

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

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	12/08/2010

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