Healthcare Provider Details

I. General information

NPI: 1457698474
Provider Name (Legal Business Name): SECRET YOUNG MFTI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2013
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 W 14TH ST
LONG BEACH CA
90813-2943
US

IV. Provider business mailing address

138 ELM AVE APT 22
LONG BEACH CA
90802-4925
US

V. Phone/Fax

Practice location:
  • Phone: 562-591-8701
  • Fax: 562-591-0235
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number71903
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: