Provider Demographics
NPI:1023861572
Name:HER SPACE THERAPY, A MARRIAGE AND FAMILY CORPORATION
Entity type:Organization
Organization Name:HER SPACE THERAPY, A MARRIAGE AND FAMILY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYLA
Authorized Official - Middle Name:G
Authorized Official - Last Name:FISK
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:626-681-3283
Mailing Address - Street 1:1680 LAS FLORES AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-1614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 S FAIR OAKS AVE STE 310
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2012
Practice Address - Country:US
Practice Address - Phone:626-681-3283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)