Healthcare Provider Details

I. General information

NPI: 1801233432
Provider Name (Legal Business Name): BETHANY CHRISTIAN SERVICES OF SOUTHERN CALIFORNIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16700 VALLEY VIEW AVE SUITE 210
LA MIRADA CA
90638-5830
US

IV. Provider business mailing address

16700 VALLEY VIEW AVE SUITE 210
LA MIRADA CA
90638-5830
US

V. Phone/Fax

Practice location:
  • Phone: 714-994-0500
  • Fax: 714-994-0515
Mailing address:
  • Phone: 714-994-0500
  • Fax: 714-994-0515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC38441
License Number StateCA

VIII. Authorized Official

Name: JEFF CARLSON
Title or Position: BRANCH DIRECTOR
Credential: MFT
Phone: 714-994-0500