Healthcare Provider Details

I. General information

NPI: 1174244263
Provider Name (Legal Business Name): CHILD & INDIVIDUAL ART THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 PACIFIC COAST HWY STE 106
HERMOSA BEACH CA
90254-2734
US

IV. Provider business mailing address

PO BOX 19
PORTOLA CA
96122-0019
US

V. Phone/Fax

Practice location:
  • Phone: 424-247-6010
  • Fax:
Mailing address:
  • Phone: 530-316-4248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER ORTEGA ORTEGA
Title or Position: BILLING & OPERATIONS MANAGER
Credential:
Phone: 530-316-4248