=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114432762
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENRICHED LIFE THERAPY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2017
-----------------------------------------------------
Last Update Date | 12/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4221 WILSHIRE BLVD STE 290-26
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-3540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-441-6780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4221 WILSHIRE BLVD STE 290-26
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-3540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-441-6780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | CHRISTINE CHAE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 213-441-6780
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 28582
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------