Provider Demographics
NPI:1891837456
Name:MAIN, MICHAEL E (MFT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:E
Last Name:MAIN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13060 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2236
Mailing Address - Country:US
Mailing Address - Phone:818-398-4405
Mailing Address - Fax:
Practice Address - Street 1:4444 W RIVERSIDE DR
Practice Address - Street 2:SUITE 307
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4073
Practice Address - Country:US
Practice Address - Phone:818-398-4405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC7168106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist