MEDICARE: KRISTINA COPLEY 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1679113765
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KRISTINA COPLEY MARRIAGE AND FAMILY THERAPY, INC

Provider Business Mailing Address
First Line	:	1267 ROSECRANS ST STE B
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-2692
Country	:	US
Telephone Number	:	619-627-1505
Fax Number	:	619-393-0754

Provider Business Practice Location Address
First Line	:	1267 ROSECRANS ST STE B
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-2692
Country	:	US
Telephone Number	:	619-627-1505
Fax Number	:	619-393-0754

Authorized Official
Title or Position	:	OWNER
Name	:	MS. KRISTINA SCIARRILLO COPLEY
Credential	:	LMFT
Telephone Number	:	619-627-1505

Provider Enumeration Date	:	01/07/2020
Last Update Date	:	01/07/2020

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