Healthcare Provider Details

I. General information

NPI: 1861347817
Provider Name (Legal Business Name): COMMUNITY WELLNESS GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11311 HAWTHORNE BLVD UNIT 1
INGLEWOOD CA
90304-2775
US

IV. Provider business mailing address

6709 LA TIJERA BLVD UNIT 1025
LOS ANGELES CA
90045-2017
US

V. Phone/Fax

Practice location:
  • Phone: 818-858-6031
  • Fax:
Mailing address:
  • Phone: 818-858-6031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: TRACY NIBO
Title or Position: PRESIDENT
Credential: LCSW
Phone: 818-858-6031