MEDICARE: PANGANIBAN MARRIAGE AND FAMILY THERAPY INC.

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

General Provider Information

NPI Number	:	1376260471
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PANGANIBAN MARRIAGE AND FAMILY THERAPY INC.

Provider Business Mailing Address
First Line	:	13223 BLACK MOUNTAIN RD # 346
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92129-2698
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16935 W BERNARDO DR STE 122
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92127-1623
Country	:	US
Telephone Number	:	858-868-5558
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MRS. KIMBERLY DIRKS PANGANIBAN
Credential	:	LMFT
Telephone Number	:	858-361-6016

Provider Enumeration Date	:	10/20/2022
Last Update Date	:	10/20/2022

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