MEDICARE: MEDIATION - COUNSELING

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	LCSW5131	CA

General Provider Information

NPI Number	:	1760923320
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDIATION - COUNSELING

Provider Business Mailing Address
First Line	:	21515 HAWTHORNE BLVD
Second Line	:	SUITE 1025
City	:	TORRANCE
State	:	CA
Zip	:	90503-6501
Country	:	US
Telephone Number	:	310-540-9128
Fax Number	:

Provider Business Practice Location Address
First Line	:	21515 HAWTHORNE BLVD
Second Line	:	SUITE 1025
City	:	TORRANCE
State	:	CA
Zip	:	90503-6501
Country	:	US
Telephone Number	:	310-540-9128
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID KENICHI KURODA
Credential	:	LCSW
Telephone Number	:	310-540-9128

Provider Enumeration Date	:	03/16/2017
Last Update Date	:	03/16/2017

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