=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205335445
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABUNDANCE PSYCHOTHERAPY CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2018
-----------------------------------------------------
Last Update Date | 10/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4221 WILSHIRE BLVD STE 170-16
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-3519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-441-6780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4221 WILSHIRE BLVD STE 170-16
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-3519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-441-6780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/THERAPIST
-----------------------------------------------------
Name | CHRISTINE CHAE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 213-441-6780
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LMFT98291
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW28582
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------