MEDICARE: DIALOGS WITH LIFE A MEDICAL CORPORATION

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	102496	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	102496	OTHER	CA	MARRIAGE & FAMILY THERAPIST

General Provider Information

NPI Number	:	1508344235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIALOGS WITH LIFE A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	465 S HUDSON AVE APT 1
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91101-5007
Country	:	US
Telephone Number	:	213-373-1938
Fax Number	:	213-226-0556

Provider Business Practice Location Address
First Line	:	1055 E COLORADO BLVD STE 5190
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91106-2327
Country	:	US
Telephone Number	:	213-373-1938
Fax Number	:	213-226-0556

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BERNARD MARTIN DOUGLAS
Credential	:	LMFT
Telephone Number	:	213-373-1938

Provider Enumeration Date	:	08/03/2018
Last Update Date	:	08/03/2018

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