Healthcare Provider Details

I. General information

NPI: 1043030174
Provider Name (Legal Business Name): SEA GLASS THERAPY AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3359 PENZANCE AVE
CHICO CA
95973-9683
US

IV. Provider business mailing address

1692 MANGROVE AVE # 137
CHICO CA
95926-2648
US

V. Phone/Fax

Practice location:
  • Phone: 405-451-5330
  • Fax:
Mailing address:
  • Phone: 405-451-5330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. KAYLYNN ADLER
Title or Position: PSYCHOTHERAPIST
Credential: LCSW
Phone: 901-326-3815