Healthcare Provider Details

I. General information

NPI: 1750028908
Provider Name (Legal Business Name): 180 URBAN COUNSELING LICENSED CLINICAL SOCIAL WORK CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4508 ATLANTIC AVE STE A517
LONG BEACH CA
90807-1520
US

IV. Provider business mailing address

4508 ATLANTIC AVE STE A517
LONG BEACH CA
90807-1520
US

V. Phone/Fax

Practice location:
  • Phone: 202-681-2660
  • Fax: 562-512-6337
Mailing address:
  • Phone: 202-681-2660
  • Fax: 562-512-6337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. KELIA PARKER
Title or Position: OWNER
Credential: LCSW
Phone: 202-681-2660