Healthcare Provider Details

I. General information

NPI: 1013755917
Provider Name (Legal Business Name): LIVE WELL PSYCHOLOGY GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11845 W OLYMPIC BLVD STE 1080W
LOS ANGELES CA
90064-5023
US

IV. Provider business mailing address

419 HILL ST APT 3
SANTA MONICA CA
90405-4284
US

V. Phone/Fax

Practice location:
  • Phone: 424-453-8084
  • Fax:
Mailing address:
  • Phone: 330-507-7441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State

VIII. Authorized Official

Name: ALEXIA HOLOVATYK
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 424-453-8089