MEDICARE: EMMY MIRIAM RUSTRIAN

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	LMFT147138	CA
2	101YM0800X	Mental Health Counselor	LPCC20953	CA

General Provider Information

NPI Number	:	1679039382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMY MIRIAM RUSTRIAN

Provider Business Mailing Address
First Line	:	18047 BEACH BLVD STE 1070
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92648-1304
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18047 BEACH BLVD STE 1070
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92648-1304
Country	:	US
Telephone Number	:	714-831-1686
Fax Number	:

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

Provider Enumeration Date	:	02/18/2019
Last Update Date	:	06/08/2026

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