Provider Demographics
NPI:1275833923
Name:HARDISTY, CORINNE MICHELLE (LMFT)
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:MICHELLE
Last Name:HARDISTY
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 1:470 E 3RD ST STE C
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1630
Mailing Address - Country:US
Mailing Address - Phone:213-620-5712
Mailing Address - Fax:213-621-4155
Practice Address - Street 1:470 E 3RD ST STE C
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1630
Practice Address - Country:US
Practice Address - Phone:213-620-5712
Practice Address - Fax:213-621-4155
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA73383106H00000X
CA97553106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program