Healthcare Provider Details

I. General information

NPI: 1497277552
Provider Name (Legal Business Name): KW COUPLES THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 07/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CONTINENTAL BLVD FL 6
EL SEGUNDO CA
90245-5074
US

IV. Provider business mailing address

PO BOX 7531
LONG BEACH CA
90807-0531
US

V. Phone/Fax

Practice location:
  • Phone: 310-751-0389
  • Fax:
Mailing address:
  • Phone: 310-751-0389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number100193
License Number StateCA

VIII. Authorized Official

Name: KIAUNDRA JACKSON
Title or Position: CEO
Credential:
Phone: 310-751-0389