Provider Demographics
NPI:1073713582
Name:REPOLA, MOIRA (MFT)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:
Last Name:REPOLA
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:PO BOX 1325
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90267-1325
Mailing Address - Country:US
Mailing Address - Phone:310-600-5502
Mailing Address - Fax:
Practice Address - Street 1:1603 AVIATION BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-2858
Practice Address - Country:US
Practice Address - Phone:310-600-5502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT40550101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health