Healthcare Provider Details

I. General information

NPI: 1447076690
Provider Name (Legal Business Name): WONDERFUL COUNSELOR HOLISTIC PSYCHIATRIC CARE A PROFESSIONAL NU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4368 EAGLE ROCK BLVD
LOS ANGELES CA
90041-3211
US

IV. Provider business mailing address

4368 EAGLE ROCK BLVD
LOS ANGELES CA
90041-3211
US

V. Phone/Fax

Practice location:
  • Phone: 314-974-7347
  • Fax: 314-843-0201
Mailing address:
  • Phone: 314-974-7347
  • Fax: 314-843-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MISS AHILA MUTHAIYA
Title or Position: OWNER
Credential:
Phone: 314-974-7347