Healthcare Provider Details

I. General information

NPI: 1962980508
Provider Name (Legal Business Name): ASHLEY NICOLE LONG LABAAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11080 W OLYMPIC BLVD
LOS ANGELES CA
90064-1937
US

IV. Provider business mailing address

11080 W OLYMPIC BLVD
LOS ANGELES CA
90064-1937
US

V. Phone/Fax

Practice location:
  • Phone: 909-599-1227
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5708
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number138486
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: