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General NPI Number Information
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NPI Number | 1689150864
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Entity Type | Organization
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Legal Business Name | URBAN RESTORATION COUNSELING CENTER
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Dates
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Enumeration Date | 07/11/2018
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Last Update Date | 07/11/2018
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Provider Practice Location Address
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Address Line | 7317 EL CAJON BLVD # 129
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City | LA MESA
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State | CA
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Zip | 91942-7434
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Country | US
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Telephone | 619-343-9543
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Fax | 619-713-2561
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Provider Business Mailing Address
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Address Line | 7317 EL CAJON BLVD # 129
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City | LA MESA
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State | CA
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Zip | 91942-7434
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Country | US
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Telephone | 619-343-9543
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Fax | 619-713-2561
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Authorized Official
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Title or Position | CO-OWNER
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Name | SHANELLE D. JOHNSON
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Credential | LMFT
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Telephone | 619-343-9543
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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 | 105060
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License Number State | CA
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