Provider Demographics
NPI:1073154415
Name:MONDRAGON, THOMAS JAMES (MFT)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JAMES
Last Name:MONDRAGON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8235 SANTA MONICA BLVD STE 309
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-5969
Mailing Address - Country:US
Mailing Address - Phone:310-779-3113
Mailing Address - Fax:
Practice Address - Street 1:8235 SANTA MONICA BLVD STE 309
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-5969
Practice Address - Country:US
Practice Address - Phone:310-779-3113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42214106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist