Provider Demographics
NPI:1972768463
Name:NODAL, EDWARD ALEXANDER (MFT INTERN)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:ALEXANDER
Last Name:NODAL
Suffix:
Gender:M
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 W MANOR ST
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-4715
Mailing Address - Country:US
Mailing Address - Phone:818-631-6698
Mailing Address - Fax:
Practice Address - Street 1:1530 W CAMERON AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2711
Practice Address - Country:US
Practice Address - Phone:626-993-3029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57114106H00000X
CA90970106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist