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: 02/06/2024
Certification Date: 02/06/2024
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

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

V. Phone/Fax

Practice location:
  • Phone: 424-247-6010
  • Fax:
Mailing address:
  • Phone: 424-247-6010
  • 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 TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANYA KAVANAUGH
Title or Position: OWNER
Credential: LMFT, ATR
Phone: 424-247-6010