Provider Demographics
NPI:1730940115
Name:EVELYN CO LICENSE MARRIAGE AND FAMILY THERAPIST INC
Entity type:Organization
Organization Name:EVELYN CO LICENSE MARRIAGE AND FAMILY THERAPIST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CO
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:323-803-3131
Mailing Address - Street 1:15714 HALLDALE AVE APT B
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-3842
Mailing Address - Country:US
Mailing Address - Phone:800-803-4584
Mailing Address - Fax:800-803-4584
Practice Address - Street 1:13323 W WASHINGTON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5163
Practice Address - Country:US
Practice Address - Phone:800-803-4584
Practice Address - Fax:800-803-4584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty