Healthcare Provider Details

I. General information

NPI: 1740694488
Provider Name (Legal Business Name): KHEPER LIFE ENRICHMENT INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3406 W 75TH ST
LOS ANGELES CA
90043-4926
US

IV. Provider business mailing address

3406 W 75TH ST
LOS ANGELES CA
90043-4926
US

V. Phone/Fax

Practice location:
  • Phone: 323-750-7550
  • Fax:
Mailing address:
  • Phone: 323-750-7550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberPSY 15637
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberPSY 15637
License Number StateCA

VIII. Authorized Official

Name: MRS. ERICA CHERYL BYRD
Title or Position: DIRECTOR, THERAPIST
Credential: MS, MFTI
Phone: 323-750-7550