Provider Demographics
NPI:1235737875
Name:BOMBOLA, TALIA (LMFT)
Entity Type:Individual
Prefix:
First Name:TALIA
Middle Name:
Last Name:BOMBOLA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5020 CAMPUS DR # 27
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2120
Mailing Address - Country:US
Mailing Address - Phone:949-478-1798
Mailing Address - Fax:
Practice Address - Street 1:5020 CAMPUS DRIVE
Practice Address - Street 2:#27
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2120
Practice Address - Country:US
Practice Address - Phone:949-478-1798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122456101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health