MEDICARE: MIKE KEMMERER 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	MFC49025	CA

General Provider Information

NPI Number	:	1508051970
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKE KEMMERER MFT

Provider Business Mailing Address
First Line	:	PO BOX 640
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90267-0640
Country	:	US
Telephone Number	:	310-922-9857
Fax Number	:

Provider Business Practice Location Address
First Line	:	710 PIER AVE
Second Line	:	OFFICE #11
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-3940
Country	:	US
Telephone Number	:	310-922-9857
Fax Number	:

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

Provider Enumeration Date	:	09/10/2007
Last Update Date	:	09/05/2012

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