Healthcare Provider Details

I. General information

NPI: 1689150864
Provider Name (Legal Business Name): URBAN RESTORATION COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7317 EL CAJON BLVD # 129
LA MESA CA
91942-7434
US

IV. Provider business mailing address

7317 EL CAJON BLVD # 129
LA MESA CA
91942-7434
US

V. Phone/Fax

Practice location:
  • Phone: 619-343-9543
  • Fax: 619-713-2561
Mailing address:
  • Phone: 619-343-9543
  • Fax: 619-713-2561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number105060
License Number StateCA

VIII. Authorized Official

Name: SHANELLE D. JOHNSON
Title or Position: CO-OWNER
Credential: LMFT
Phone: 619-343-9543