Healthcare Provider Details

I. General information

NPI: 1699246272
Provider Name (Legal Business Name): CREATE REALISTIC CHANGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2018
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1873 W 54TH ST
LOS ANGELES CA
90062-2604
US

IV. Provider business mailing address

531 MAIN ST STE 1132
EL SEGUNDO CA
90245-3060
US

V. Phone/Fax

Practice location:
  • Phone: 424-222-1795
  • Fax:
Mailing address:
  • Phone: 424-222-1795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. CALIFIA ABWOON
Title or Position: FOUNDER AND DIRECTOR
Credential: RECOVERY PRACTIONER
Phone: 424-222-1795