MEDICARE: CHILD & INDIVIDUAL ART THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1174244263
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILD & INDIVIDUAL ART THERAPY

Provider Business Mailing Address
First Line	:	2401 PACIFIC COAST HWY STE 106
Second Line	:
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-2734
Country	:	US
Telephone Number	:	424-247-6010
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 PACIFIC COAST HWY STE 106
Second Line	:
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-2734
Country	:	US
Telephone Number	:	424-247-6010
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ANYA KAVANAUGH
Credential	:	LMFT, ATR
Telephone Number	:	424-247-6010

Provider Enumeration Date	:	09/07/2022
Last Update Date	:	02/06/2024

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