MEDICARE: BETH HOLDER LICENSED 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	:	1659944361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BETH HOLDER LICENSED MARRIAGE AND FAMILY THERAPY INC

Provider Business Mailing Address
First Line	:	302 N EL CAMINO REAL STE 202
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-4778
Country	:	US
Telephone Number	:	949-842-7884
Fax Number	:	949-272-5541

Provider Business Practice Location Address
First Line	:	302 N EL CAMINO REAL STE 202
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-4778
Country	:	US
Telephone Number	:	949-842-7884
Fax Number	:	949-272-5541

Authorized Official
Title or Position	:	DIRECTOR
Name	:	BETHANY HOLDER
Credential	:	LMFT
Telephone Number	:	949-842-7884

Provider Enumeration Date	:	07/20/2021
Last Update Date	:	07/20/2021

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