Provider Demographics
NPI:1023645322
Name:CLEARY, JOSH ALFRED
Entity type:Individual
Prefix:
First Name:JOSH
Middle Name:ALFRED
Last Name:CLEARY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4721 LA VILLA MARINA UNIT A
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-7015
Mailing Address - Country:US
Mailing Address - Phone:310-721-9549
Mailing Address - Fax:
Practice Address - Street 1:11303 WILSHIRE BLVD BLDG 116
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5069
Practice Address - Country:US
Practice Address - Phone:310-721-9549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT118149106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist