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General NPI Number Information
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NPI Number | 1093052565
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Entity Type | Organization
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Legal Business Name | IM POSSIBLE YOUTH FOUNDATION
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Dates
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Enumeration Date | 01/03/2013
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Last Update Date | 01/03/2013
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Provider Practice Location Address
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Address Line | 11011 CRENSHAW BLVD SUITE 203
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City | INGLEWOOD
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State | CA
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Zip | 90303-6330
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Country | US
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Telephone | 310-677-7080
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Fax | 866-894-5431
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Provider Business Mailing Address
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Address Line | 11011 CRENSHAW BLVD SUITE 203
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City | INGLEWOOD
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State | CA
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Zip | 90303-6330
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Country | US
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Telephone | 310-677-7080
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Fax | 866-894-5431
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Authorized Official
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Title or Position | CHEIF EXECUTIVE OFFICER
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Name | MISS MILLICENT SHUNGU MAZAUWABA
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Credential | M.A.
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Telephone | 310-677-7080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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