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General NPI Number Information
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NPI Number | 1629559802
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Entity Type | Organization
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Legal Business Name | SKT THERAPY INC
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Dates
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Enumeration Date | 08/24/2018
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Last Update Date | 05/19/2021
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Provider Practice Location Address
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Address Line | 765 N MAIN ST STE 130-A10
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City | CORONA
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State | CA
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Zip | 92878-1440
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Country | US
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Telephone | 650-252-0300
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Fax |
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Provider Business Mailing Address
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Address Line | 765 N MAIN ST STE 130-A10
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City | CORONA
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State | CA
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Zip | 92878-1440
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Country | US
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Telephone | 650-252-0300
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Fax | 951-735-7113
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Authorized Official
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Title or Position | OWNER
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Name | SHANNON KLOSAK
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Credential | LMFT
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Telephone | 650-252-0300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 93637
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License Number State | CA
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