Provider Demographics
NPI:1265551048
Name:GARREN, EDWARD GEORGE (MA LMFT CA)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:GEORGE
Last Name:GARREN
Suffix:
Gender:M
Credentials:MA LMFT CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3781 1/2 CIMARRON ST
Mailing Address - Street 2:UPSTAIRS
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-4463
Mailing Address - Country:US
Mailing Address - Phone:213-596-9674
Mailing Address - Fax:213-596-9082
Practice Address - Street 1:3781 1/2 CIMARRON ST
Practice Address - Street 2:UPSTAIRS
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-4463
Practice Address - Country:US
Practice Address - Phone:213-596-9674
Practice Address - Fax:213-596-9082
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC27181106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR271177Medicaid
OR271177Medicaid
1235164559Medicare UPIN