MEDICARE: LIFEBLOOM MARRIAGE AND FAMILY THERAPY 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1932952835
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFEBLOOM MARRIAGE AND FAMILY THERAPY INC.

Provider Business Mailing Address
First Line	:	3405 VETERAN AVE APT 4
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-5341
Country	:	US
Telephone Number	:	209-505-1656
Fax Number	:

Provider Business Practice Location Address
First Line	:	3405 VETERAN AVE APT 4
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-5341
Country	:	US
Telephone Number	:	209-505-1656
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KEISHA LIBBRECHT
Credential	:	LMFT
Telephone Number	:	209-505-1656

Provider Enumeration Date	:	04/09/2024
Last Update Date	:	04/09/2024

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