Provider Demographics
NPI:1144705724
Name:WINGS OF THE FUTURE PRIVATE PRACTICE LCSW PC
Entity type:Organization
Organization Name:WINGS OF THE FUTURE PRIVATE PRACTICE LCSW PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOOTHE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:661-402-1545
Mailing Address - Street 1:117 E COLORADO BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-1938
Mailing Address - Country:US
Mailing Address - Phone:661-402-1545
Mailing Address - Fax:661-727-0006
Practice Address - Street 1:117 E COLORADO BLVD STE 3600
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-1938
Practice Address - Country:US
Practice Address - Phone:661-402-1545
Practice Address - Fax:661-727-0006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-28
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA03066046OtherBUSINESS LICENSE
CACB394408OtherGROUP