Provider Demographics
NPI:1235589946
Name:DONNA S BALTAS MFT AN INDIVIDUAL COUPLE AND FAMILY COUNSELING CORP
Entity Type:Organization
Organization Name:DONNA S BALTAS MFT AN INDIVIDUAL COUPLE AND FAMILY COUNSELING CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BALTAS
Authorized Official - Suffix:
Authorized Official - Credentials:MFC 41475
Authorized Official - Phone:310-251-1658
Mailing Address - Street 1:415 NORTH CAMDEN DRIVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4436
Mailing Address - Country:US
Mailing Address - Phone:310-251-1658
Mailing Address - Fax:
Practice Address - Street 1:415 NORTH CAMDEN DRIVE
Practice Address - Street 2:SUITE 111
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4436
Practice Address - Country:US
Practice Address - Phone:310-251-1658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41475106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty