1417370420 NPI number — MATTHEW DONALD MISURACA MA, LMFT

Table of content: MATTHEW DONALD MISURACA MA, LMFT (NPI 1417370420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417370420 NPI number — MATTHEW DONALD MISURACA MA, LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MISURACA
Provider First Name:
MATTHEW
Provider Middle Name:
DONALD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417370420
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
74133 EL PASEO
Provider Second Line Business Mailing Address:
SUITE 11
Provider Business Mailing Address City Name:
PALM DESERT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92260-4119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-708-8253
Provider Business Mailing Address Fax Number:
760-779-5600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
74133 EL PASEO
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92260-4119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-708-8253
Provider Business Practice Location Address Fax Number:
760-779-5600
Provider Enumeration Date:
01/27/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MFC 53014 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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