Healthcare Provider Details

I. General information

NPI: 1215678065
Provider Name (Legal Business Name): ISABELLA C DUTRA LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 YALE ST STE 3
SANTA MONICA CA
90403-4774
US

IV. Provider business mailing address

1150 YALE ST STE 3
SANTA MONICA CA
90403-4774
US

V. Phone/Fax

Practice location:
  • Phone: 847-612-0291
  • Fax:
Mailing address:
  • Phone: 847-612-0291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number22477
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: