Healthcare Provider Details

I. General information

NPI: 1659191179
Provider Name (Legal Business Name): PINK MOON HC A LICENSED CLINICAL SOCIAL WORKER CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 N RENO ST
LOS ANGELES CA
90026-4507
US

IV. Provider business mailing address

341 N RENO ST
LOS ANGELES CA
90026-4507
US

V. Phone/Fax

Practice location:
  • Phone: 213-703-6234
  • Fax:
Mailing address:
  • Phone: 213-703-6234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. AUBRI GOMEZ
Title or Position: FOUNDER/PSYCHOTHERAPIST
Credential: LCSW
Phone: 213-703-6234