MEDICARE: INCREDIBLY INSPIRATIONAL, INC

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	251S00000X	Community/Behavioral Health Agency	LCS 16061	CA

General Provider Information

NPI Number	:	1639558232
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INCREDIBLY INSPIRATIONAL, INC

Provider Business Mailing Address
First Line	:	6305 E ELIOT ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90803-2205
Country	:	US
Telephone Number	:	562-743-2389
Fax Number	:

Provider Business Practice Location Address
First Line	:	2009 PALO VERDE AVE STE A
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90815-3322
Country	:	US
Telephone Number	:	562-743-2389
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MS. KATHERINE ELAINE ERICKSON
Credential	:	LCSW
Telephone Number	:	562-743-2389

Provider Enumeration Date	:	05/28/2015
Last Update Date	:	05/28/2015

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