Provider Demographics
NPI:1508344235
Name:DIALOGS WITH LIFE A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DIALOGS WITH LIFE A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:213-373-1938
Mailing Address - Street 1:465 S HUDSON AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-5007
Mailing Address - Country:US
Mailing Address - Phone:213-373-1938
Mailing Address - Fax:213-226-0556
Practice Address - Street 1:1055 E COLORADO BLVD STE 5190
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2327
Practice Address - Country:US
Practice Address - Phone:213-373-1938
Practice Address - Fax:213-226-0556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102496106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA102496OtherMARRIAGE & FAMILY THERAPIST