Provider Demographics
NPI:1124493184
Name:THE HOLLYWOOD THERAPIST
Entity type:Organization
Organization Name:THE HOLLYWOOD THERAPIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MARRIAGE FAMILY THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:HUGH
Authorized Official - Last Name:HAUCK
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:619-309-8291
Mailing Address - Street 1:7104 FRANKLIN AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-3023
Mailing Address - Country:US
Mailing Address - Phone:619-309-8291
Mailing Address - Fax:
Practice Address - Street 1:7104 FRANKLIN AVE APT 12
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-3023
Practice Address - Country:US
Practice Address - Phone:619-309-8291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54004251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health