Basic Information
| Provider Information | |||||||||
| NPI: | 1114058823 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIYABE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5829 OCEAN TERRACE DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO PALOS VERDES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902755758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108030448 | ||||||||
| FaxNumber: | 3105415601 | ||||||||
| Practice Location | |||||||||
| Address1: | 370 CRENSHAW BLVD | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905031727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107871500 | ||||||||
| FaxNumber: | 3107878045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFT 9430 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.