Healthcare Provider Details

I. General information

NPI: 1003394149
Provider Name (Legal Business Name): NEURO WELLNESS SPA, A MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N SEPULVEDA BLVD STE 201
MANHATTAN BEACH CA
90266-5963
US

IV. Provider business mailing address

18119 PRAIRIE AVE
TORRANCE CA
90504-3739
US

V. Phone/Fax

Practice location:
  • Phone: 310-545-4450
  • Fax: 310-564-2295
Mailing address:
  • Phone: 877-847-3984
  • Fax: 888-383-5708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG78080
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARTHA KOO
Title or Position: CMO
Credential: MD
Phone: 877-847-3984