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General NPI Number Information
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NPI Number | 1871738112
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Entity Type | Organization
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Legal Business Name | TELECONNECT THERAPIES
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Dates
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Enumeration Date | 12/15/2008
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Last Update Date | 04/26/2013
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Provider Practice Location Address
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Address Line | 22 CANYON TERRACE
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City | AVALON
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State | CA
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Zip | 90704
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Country | US
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Telephone | 310-850-2960
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1665
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City | AVALON
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State | CA
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Zip | 90704-1665
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Country | US
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Telephone | 310-850-2960
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | DAWN MARIE SAMPSON
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Credential | LCSW
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Telephone | 310-850-2960
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY21275
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCS23139
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License Number State | CA
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