Provider Demographics
NPI:1003255506
Name:PERRY, COLLEEN (MFT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 GLENCOE AVE APT 613
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6689
Mailing Address - Country:US
Mailing Address - Phone:310-259-8970
Mailing Address - Fax:
Practice Address - Street 1:4140 GLENCOE AVE APT 613
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6689
Practice Address - Country:US
Practice Address - Phone:310-259-8970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC38937106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist