Healthcare Provider Details

I. General information

NPI: 1558912915
Provider Name (Legal Business Name): TELINA MICHELLE GRACE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14240 IMPERIAL HWY
LA MIRADA CA
90638-1940
US

IV. Provider business mailing address

11927 ELLIOTT AVE
EL MONTE CA
91732-3740
US

V. Phone/Fax

Practice location:
  • Phone: 562-946-1587
  • Fax: 562-946-5740
Mailing address:
  • Phone: 909-992-8008
  • Fax: 626-350-0756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number150410
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: