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General NPI Number Information
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NPI Number | 1487415824
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Entity Type | Organization
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Legal Business Name | VANTAGE THERAPY A LICENSED CLINICAL SOCIAL WORKER CORPORATION
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Dates
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Enumeration Date | 01/23/2024
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Last Update Date | 02/01/2024
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Provider Practice Location Address
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Address Line | 2001 VESTAL AVE APT 3
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City | LOS ANGELES
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State | CA
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Zip | 90026-1967
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Country | US
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Telephone | 207-712-0470
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 261044
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City | LOS ANGELES
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State | CA
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Zip | 90026-0707
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | EMILY HARRIS
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Credential | LCSW
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Telephone | 207-712-0470
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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