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General NPI Number Information
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NPI Number | 1417378704
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Entity Type | Organization
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Legal Business Name | EDUCATIONAL AND DEVELOPMENTAL THERAPIES
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Dates
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Enumeration Date | 01/03/2014
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Last Update Date | 01/03/2014
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Provider Practice Location Address
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Address Line | 2249 20TH ST SUITE 101
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City | SANTA MONICA
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State | CA
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Zip | 90405-1742
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Country | US
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Telephone | 310-450-8004
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Fax | 310-450-8004
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Provider Business Mailing Address
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Address Line | 2249 20TH ST SUITE 101
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City | SANTA MONICA
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State | CA
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Zip | 90405-1742
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Country | US
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Telephone | 310-450-8004
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Fax | 310-450-8004
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | MR. MAXWELL RANEY BROOKS
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Credential |
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Telephone | 310-450-8004
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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 | 093343
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License Number State | CA
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