=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740694488
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KHEPER LIFE ENRICHMENT INSTITUTE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2014
-----------------------------------------------------
Last Update Date | 06/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3406 W 75TH ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90043-4926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-750-7550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3406 W 75TH ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90043-4926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-750-7550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, THERAPIST
-----------------------------------------------------
Name | MRS. ERICA CHERYL BYRD
-----------------------------------------------------
Credential | MS, MFTI
-----------------------------------------------------
Telephone | 323-750-7550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | PSY 15637
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | PSY 15637
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------