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General NPI Number Information
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NPI Number | 1730745076
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Entity Type | Organization
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Legal Business Name | KINTSUGI HEALTH
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Dates
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Enumeration Date | 05/13/2019
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Last Update Date | 05/13/2019
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Provider Practice Location Address
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Address Line | 24012 CALLE DE LA PLATA STE 430
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City | LAGUNA HILLS
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State | CA
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Zip | 92653-7623
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Country | US
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Telephone | 949-500-8833
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Fax |
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Provider Business Mailing Address
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Address Line | 24012 CALLE DE LA PLATA STE 430
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City | LAGUNA HILLS
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State | CA
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Zip | 92653-7623
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Country | US
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Telephone | 949-500-8833
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. TATYANA ELLISON
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Credential | MD
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Telephone | 949-500-8833
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #11
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #12
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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