Healthcare Provider Details

I. General information

NPI: 1003135906
Provider Name (Legal Business Name): PSYCHOLOGICAL CARE AND HEALING TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11965 VENICE BLVD SUITE 407
LOS ANGELES CA
90066-3979
US

IV. Provider business mailing address

11965 VENICE BLVD SUITE 407
LOS ANGELES CA
90066-3979
US

V. Phone/Fax

Practice location:
  • Phone: 310-566-7625
  • Fax: 310-566-7629
Mailing address:
  • Phone: 310-566-7625
  • Fax: 310-566-7629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JEFFERY BALL
Title or Position: EXECUTIVE AND CLINICAL DIRECTOR
Credential: PHD
Phone: 310-571-8040