MEDICARE: TEUGBYEOLHAN, LICENSED CLINICAL SOCIAL WORKER, 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
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1770172371
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEUGBYEOLHAN, LICENSED CLINICAL SOCIAL WORKER, INC.

Provider Business Mailing Address
First Line	:	553 N PACIFIC COAST HWY STE 337B
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-2105
Country	:	US
Telephone Number	:	626-665-2557
Fax Number	:

Provider Business Practice Location Address
First Line	:	1611 S PACIFIC COAST HWY STE 205A
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5611
Country	:	US
Telephone Number	:	626-665-2557
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	FONDA TOKUSHIGE
Credential	:	LCSW
Telephone Number	:	424-262-2454

Provider Enumeration Date	:	01/18/2021
Last Update Date	:	06/03/2025

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