Healthcare Provider Details

I. General information

NPI: 1801528773
Provider Name (Legal Business Name): SHAPE 4 FAMILIES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 TECHNOLOGY DR STE 118
IRVINE CA
92618-2310
US

IV. Provider business mailing address

18 TECHNOLOGY DR STE 118
IRVINE CA
92618-2310
US

V. Phone/Fax

Practice location:
  • Phone: 949-922-1115
  • Fax:
Mailing address:
  • Phone: 949-922-1115
  • 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 Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KARL STENSKE
Title or Position: SECRETARY/ TREASURER
Credential:
Phone: 949-922-1115