Healthcare Provider Details

I. General information

NPI: 1124878574
Provider Name (Legal Business Name): MY LA THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 OCEAN PARK BLVD UNIT 232
SANTA MONICA CA
90405-3566
US

IV. Provider business mailing address

130 OCEAN PARK BLVD UNIT 232
SANTA MONICA CA
90405-3566
US

V. Phone/Fax

Practice location:
  • Phone: 949-295-0980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: BROOKE SPROWL
Title or Position: OWNER/FOUNDER
Credential:
Phone: 949-295-0980