Healthcare Provider Details

I. General information

NPI: 1730940115
Provider Name (Legal Business Name): EVELYN CO LICENSE MARRIAGE AND FAMILY THERAPIST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13323 W WASHINGTON BLVD STE 200
LOS ANGELES CA
90066-5163
US

IV. Provider business mailing address

15714 HALLDALE AVE APT B
GARDENA CA
90247-3842
US

V. Phone/Fax

Practice location:
  • Phone: 800-803-4584
  • Fax: 800-803-4584
Mailing address:
  • Phone: 800-803-4584
  • Fax: 800-803-4584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. EVELYN CO
Title or Position: CEO
Credential: LMFT
Phone: 323-803-3131