Provider Demographics
NPI:1114058823
Name:MIYABE, JOHN DAVID (MFT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DAVID
Last Name:MIYABE
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 1:5829 OCEAN TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-5758
Mailing Address - Country:US
Mailing Address - Phone:310-803-0448
Mailing Address - Fax:310-541-5601
Practice Address - Street 1:370 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1727
Practice Address - Country:US
Practice Address - Phone:310-787-1500
Practice Address - Fax:310-787-8045
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 9430106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist