Healthcare Provider Details

I. General information

NPI: 1982804571
Provider Name (Legal Business Name): MS. KANISHA MARIE MCREYNOLDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 WILSHIRE BLVD SUITE 500
LOS ANGELES CA
90017-1908
US

IV. Provider business mailing address

1200 WILSHIRE BLVD SUITE 500
LOS ANGELES CA
90017-1908
US

V. Phone/Fax

Practice location:
  • Phone: 213-481-7464
  • Fax: 213-481-7147
Mailing address:
  • Phone: 213-481-7464
  • Fax: 213-481-7147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number53357
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: