Healthcare Provider Details

I. General information

NPI: 1639606221
Provider Name (Legal Business Name): 1404 FAMILY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 05/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24050 MADISON ST STE 200
TORRANCE CA
90505-6016
US

IV. Provider business mailing address

508 S PACIFIC COAST HWY
REDONDO BEACH CA
90277-4219
US

V. Phone/Fax

Practice location:
  • Phone: 310-291-9997
  • Fax:
Mailing address:
  • Phone: 310-291-9997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW70063
License Number StateCA

VIII. Authorized Official

Name: MS. CYNTHIA SORIA
Title or Position: OWNER
Credential: LCSW
Phone: 310-291-9997