Healthcare Provider Details

I. General information

NPI: 1568222776
Provider Name (Legal Business Name): ACT5 COMMUNITY LIAISON CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2024
Last Update Date: 04/06/2024
Certification Date: 04/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 DEEP VALLEY DR STE 2411
PALOS VERDES PEN CA
90274
US

IV. Provider business mailing address

955 DEEP VALLEY DR STE 2411
PALOS VERDES PEN CA
90274
US

V. Phone/Fax

Practice location:
  • Phone: 424-262-7775
  • Fax:
Mailing address:
  • Phone: 424-262-7775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. KALINA NOELLE
Title or Position: PSYCHOLOGIST
Credential: PSYD
Phone: 424-262-7775