Healthcare Provider Details

I. General information

NPI: 1033070669
Provider Name (Legal Business Name): COURAGEOUS LOVE WORKS THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 N TEXAS ST STE 201
FAIRFIELD CA
94533-5623
US

IV. Provider business mailing address

1545 N TEXAS ST STE 201
FAIRFIELD CA
94533-5623
US

V. Phone/Fax

Practice location:
  • Phone: 415-413-8592
  • Fax:
Mailing address:
  • Phone: 415-000-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EXECUTIVE DIRECTOR
Title or Position: DIRECTOR
Credential:
Phone: 415-000-0000