Healthcare Provider Details

I. General information

NPI: 1407605546
Provider Name (Legal Business Name): THERAPY COLLECTIVE OF CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2024
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 N SAN VICENTE BLVD STE 256
BEVERLY HILLS CA
90211-2329
US

IV. Provider business mailing address

113 N SAN VICENTE BLVD STE 256
BEVERLY HILLS CA
90211-2329
US

V. Phone/Fax

Practice location:
  • Phone: 805-409-7101
  • Fax:
Mailing address:
  • Phone: 805-409-7101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA POTTHOFF
Title or Position: CEO
Credential: LMFT
Phone: 310-925-3357