Provider Demographics
NPI:1548953789
Name:TELETHERAPY ROOM, A LICENSED PROFESSIONAL CLINICAL COUNSELOR, CORP.
Entity type:Organization
Organization Name:TELETHERAPY ROOM, A LICENSED PROFESSIONAL CLINICAL COUNSELOR, CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLINOR
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LCMHC
Authorized Official - Phone:888-725-8085
Mailing Address - Street 1:4740 MISSION GORGE PL UNIT 601147
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-7047
Mailing Address - Country:US
Mailing Address - Phone:888-725-8085
Mailing Address - Fax:
Practice Address - Street 1:10462 SAN DIEGO MISSION RD UNIT 18
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2255
Practice Address - Country:US
Practice Address - Phone:888-725-8085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty