Provider Demographics
NPI:1164701579
Name:LAW-GLASSMAN, MINA (MFT)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:LAW-GLASSMAN
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 1:1048 IRVINE AVE
Mailing Address - Street 2:#125
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-4602
Mailing Address - Country:US
Mailing Address - Phone:949-246-1190
Mailing Address - Fax:949-548-0702
Practice Address - Street 1:3151 AIRWAY AVENUE
Practice Address - Street 2:SUITE L-1
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-246-1190
Practice Address - Fax:949-548-0702
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 47369106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist