MEDICARE: ELEVATELIFE THERAPY & CONSULTING, LICENSED CLINICAL SOCIAL WORKER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1457133357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEVATELIFE THERAPY & CONSULTING, LICENSED CLINICAL SOCIAL WORKER, INC

Provider Business Mailing Address
First Line	:	145 S FAIRFAX AVE STE 200
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-2186
Country	:	US
Telephone Number	:	323-968-6404
Fax Number	:	213-315-4859

Provider Business Practice Location Address
First Line	:	145 S FAIRFAX AVE STE 200
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-2186
Country	:	US
Telephone Number	:	323-968-6404
Fax Number	:	213-315-4859

Authorized Official
Title or Position	:	OWNER
Name	:	ANGELIQUE D YORK
Credential	:	LCSW MSW
Telephone Number	:	323-968-6404

Provider Enumeration Date	:	10/16/2023
Last Update Date	:	11/13/2023

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