MEDICARE: 180 URBAN COUNSELING LICENSED CLINICAL SOCIAL WORK CORP.

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	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1750028908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	180 URBAN COUNSELING LICENSED CLINICAL SOCIAL WORK CORP.

Provider Business Mailing Address
First Line	:	4508 ATLANTIC AVE STE A517
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-1520
Country	:	US
Telephone Number	:	202-681-2660
Fax Number	:	562-512-6337

Provider Business Practice Location Address
First Line	:	4508 ATLANTIC AVE STE A517
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-1520
Country	:	US
Telephone Number	:	202-681-2660
Fax Number	:	562-512-6337

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. KELIA PARKER
Credential	:	LCSW
Telephone Number	:	202-681-2660

Provider Enumeration Date	:	05/18/2022
Last Update Date	:	05/18/2022

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