Healthcare Provider Details

I. General information

NPI: 1013537141
Provider Name (Legal Business Name): CUCUMBER WELLNESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2020
Last Update Date: 04/18/2020
Certification Date: 04/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 GREAT AMERICA PKWY STE 320
SANTA CLARA CA
95054-1140
US

IV. Provider business mailing address

12301 WILSHIRE BLVD STE 512
LOS ANGELES CA
90025-1021
US

V. Phone/Fax

Practice location:
  • Phone: 833-427-3566
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. LAWRENCE GENEN
Title or Position: OWNER
Credential: MD
Phone: 833-427-3566