Provider Demographics
NPI:1972834299
Name:COLVIN INDIVIDUAL AND FAMILY THERAPY
Entity Type:Organization
Organization Name:COLVIN INDIVIDUAL AND FAMILY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:HARPER
Authorized Official - Last Name:COLVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-290-4922
Mailing Address - Street 1:2900 BRISTOL ST
Mailing Address - Street 2:SUITE A207
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5981
Mailing Address - Country:US
Mailing Address - Phone:949-290-4922
Mailing Address - Fax:
Practice Address - Street 1:2900 BRISTOL ST
Practice Address - Street 2:SUITE A207
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5981
Practice Address - Country:US
Practice Address - Phone:949-290-4922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 44052106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty