=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932952835
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFEBLOOM MARRIAGE AND FAMILY THERAPY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2024
-----------------------------------------------------
Last Update Date | 04/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3405 VETERAN AVE APT 4
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90034-5341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-505-1656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3405 VETERAN AVE APT 4
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90034-5341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-505-1656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KEISHA LIBBRECHT
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 209-505-1656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------