Provider Demographics
NPI:1073171021
Name:THRIVE INTEGRATIVE WELLNESS
Entity Type:Organization
Organization Name:THRIVE INTEGRATIVE WELLNESS
Other - Org Name:DIVINITY RECOVERY
Other - Org Type:Other Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSSUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-490-9741
Mailing Address - Street 1:20301 VENTURA BLVD STE 121
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-2447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20301 VENTURA BLVD STE 121
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2447
Practice Address - Country:US
Practice Address - Phone:310-490-9741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-04
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder