=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265242622
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISSELLA LEE GLENNON-BOATRIGHT MFT, PCC, CWC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2025
-----------------------------------------------------
Last Update Date | 01/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2021 SPERRY AVE
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93003-7408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-699-1263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6363 ALTA VISTA RIDGE RD
-----------------------------------------------------
City | SIMI VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93063-4745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-791-4428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 16206
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number | 2508C30AF6
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 145852
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------