MEDICARE: MRS. IVY AUTUMN HECK M.A.

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	52515	CA

General Provider Information

NPI Number	:	1265798458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. IVY AUTUMN HECK M.A.

Provider Business Mailing Address
First Line	:	1848 S ELENA AVE STE 105
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5710
Country	:	US
Telephone Number	:	424-254-4200
Fax Number	:	310-540-4580

Provider Business Practice Location Address
First Line	:	1848 S ELENA AVE STE 105
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5710
Country	:	US
Telephone Number	:	424-254-4200
Fax Number	:	310-540-4580

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

Provider Enumeration Date	:	04/02/2012
Last Update Date	:	03/19/2019

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