Healthcare Provider Details

I. General information

NPI: 1083309686
Provider Name (Legal Business Name): ECLECTIC MINDS THERAPY A MARRIAGE AND FAMILY THERAPY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 E MICHELSON ST
LONG BEACH CA
90805-4845
US

IV. Provider business mailing address

1241 E MICHELSON ST
LONG BEACH CA
90805-4845
US

V. Phone/Fax

Practice location:
  • Phone: 562-756-8161
  • Fax:
Mailing address:
  • Phone: 562-756-8161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: ADRINA WILSON
Title or Position: CEO
Credential: LMFT 107939
Phone: 562-756-8161