Provider Demographics
NPI:1518411487
Name:COOPERSMITH, TRISTAN (MFT)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:COOPERSMITH
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 1:936 HERMOSA AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-4165
Mailing Address - Country:US
Mailing Address - Phone:310-614-8053
Mailing Address - Fax:
Practice Address - Street 1:936 HERMOSA AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-4165
Practice Address - Country:US
Practice Address - Phone:310-614-8053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94551106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist