Provider Demographics
NPI:1710345715
Name:AIRPORT MARINA COUNSELING SERVICE
Entity Type:Organization
Organization Name:AIRPORT MARINA COUNSELING SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECTUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA-BALIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:310-670-1410
Mailing Address - Street 1:7891 LA TIJERA BLVD
Mailing Address - Street 2:NONE
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3145
Mailing Address - Country:US
Mailing Address - Phone:310-670-1410
Mailing Address - Fax:310-670-0919
Practice Address - Street 1:7891 LA TIJERA BLVD
Practice Address - Street 2:NONE
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3145
Practice Address - Country:US
Practice Address - Phone:310-670-1410
Practice Address - Fax:310-670-0919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960000174101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA960000174OtherSTATE OF CALIFORNIA DEPARTMENT OF PUBLIC HEALTH