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General NPI Number Information
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NPI Number | 1235342973
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Entity Type | Organization
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Legal Business Name | WINGS OF REFUGE
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Dates
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Enumeration Date | 05/08/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5777 W CENTURY BLVD SUITE 910
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City | LOS ANGELES
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State | CA
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Zip | 90045-5600
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Country | US
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Telephone | 310-670-6767
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Fax | 310-670-2626
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Provider Business Mailing Address
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Address Line | 5777 W CENTURY BLVD SUITE 910
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City | LOS ANGELES
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State | CA
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Zip | 90045-5600
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Country | US
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Telephone | 310-670-6767
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Fax | 310-670-2626
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MS. THERESA STEVENSON
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Credential | PHD
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Telephone | 310-671-6767
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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