Healthcare Provider Details

I. General information

NPI: 1366910960
Provider Name (Legal Business Name): BEYOND DETENTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12821 NEWPORT AVE
TUSTIN CA
92780-2711
US

IV. Provider business mailing address

12821 NEWPORT AVE
TUSTIN CA
92780-2711
US

V. Phone/Fax

Practice location:
  • Phone: 657-333-5805
  • Fax:
Mailing address:
  • Phone: 657-333-5805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: NICOLE CARSON
Title or Position: CEO
Credential: LMFT, PPSC
Phone: 657-333-5805