Provider Demographics
NPI:1396893772
Name:FRYBACK, MICHELLE LYNN (MFT)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LYNN
Last Name:FRYBACK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W GRAND AVE
Mailing Address - Street 2:STE #7
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3700
Mailing Address - Country:US
Mailing Address - Phone:310-784-7717
Mailing Address - Fax:310-326-1030
Practice Address - Street 1:302 W GRAND AVE
Practice Address - Street 2:STE #7
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3700
Practice Address - Country:US
Practice Address - Phone:310-784-7717
Practice Address - Fax:310-326-1030
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39858106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist