Healthcare Provider Details

I. General information

NPI: 1033796669
Provider Name (Legal Business Name): CITY2VILLAGE INTERNATIONAL INITIATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2021
Last Update Date: 03/28/2021
Certification Date: 03/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18726 S WESTERN AVE STE 403
GARDENA CA
90248-3858
US

IV. Provider business mailing address

335 E ALBERTONI ST STE 200-722
CARSON CA
90746-1425
US

V. Phone/Fax

Practice location:
  • Phone: 310-769-5710
  • Fax: 844-850-5892
Mailing address:
  • Phone: 310-738-9271
  • Fax: 844-850-5892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. NYIEMA DESIREE' CARTER
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PSYD
Phone: 310-738-9271