Basic Information
| Provider Information | |||||||||
| NPI: | 1558720904 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PACIFIC MARRIAGE & FAMILY THERAPY NETWORK, A PROFESSIONAL CORPORATION | ||||||||
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| OtherOrganizationName: | PACIFIC MFT NETWORK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2716 OCEAN PARK BLVD STE 3075 | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904055232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106122998 | ||||||||
| FaxNumber: | 3109432590 | ||||||||
| Practice Location | |||||||||
| Address1: | 2716 OCEAN PARK BLVD STE 3075 | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904055232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106122998 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2016 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEVINGTON | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | KOVACS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3102262826 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MA, MFT | ||||||||
| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 53455 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.