MEDICARE: MRS. EMILY NICOLE DUAL M.A., MFT INTERN

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	IMF 52240	CA

General Provider Information

NPI Number	:	1801920228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. EMILY NICOLE DUAL M.A., MFT INTERN

Provider Business Mailing Address
First Line	:	2116 ARLINGTON AVE
Second Line	:	SUITE 200
City	:	LOS ANGELES
State	:	CA
Zip	:	90018-1336
Country	:	US
Telephone Number	:	562-388-7805
Fax Number	:	562-388-7663

Provider Business Practice Location Address
First Line	:	2116 ARLINGTON AVE
Second Line	:	SUITE 200
City	:	LOS ANGELES
State	:	CA
Zip	:	90018-1336
Country	:	US
Telephone Number	:	562-388-7805
Fax Number	:	562-388-7663

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

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	07/08/2007

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