MEDICARE: AMELIE NELLY FERY

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	130402	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	62308	OTHER	CA	CIGNA

General Provider Information

NPI Number	:	1710634373
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMELIE NELLY FERY

Provider Business Mailing Address
First Line	:	26895 ALISO CREEK RD # B616
Second Line	:
City	:	ALISO VIEJO
State	:	CA
Zip	:	92656-5301
Country	:	US
Telephone Number	:	949-563-3709
Fax Number	:

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	:	619-356-0774
Fax Number	:

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

Provider Enumeration Date	:	03/03/2022
Last Update Date	:	03/07/2022

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