=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659191179
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINK MOON HC A LICENSED CLINICAL SOCIAL WORKER CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2024
-----------------------------------------------------
Last Update Date | 10/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 341 N RENO ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90026-4507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-703-6234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 341 N RENO ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90026-4507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-703-6234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/PSYCHOTHERAPIST
-----------------------------------------------------
Name | MR. AUBRI GOMEZ
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 213-703-6234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------