Healthcare Provider Details

I. General information

NPI: 1194481556
Provider Name (Legal Business Name): WINGS OF THE FUTURE, NFP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N LAKE AVE FL 8
PASADENA CA
91101-1849
US

IV. Provider business mailing address

851 S SUNSET AVE APT 119
WEST COVINA CA
91790-5546
US

V. Phone/Fax

Practice location:
  • Phone: 661-402-1545
  • Fax: 661-727-0006
Mailing address:
  • Phone: 310-621-0150
  • Fax: 661-727-0006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: KRYSTAL MARIE BOOTHE
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 661-402-1545