Provider Demographics
NPI:1093052565
Name:IM POSSIBLE YOUTH FOUNDATION
Entity Type:Organization
Organization Name:IM POSSIBLE YOUTH FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEIF EXECUTIVE OFFICER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MILLICENT
Authorized Official - Middle Name:SHUNGU
Authorized Official - Last Name:MAZAUWABA
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:310-677-7080
Mailing Address - Street 1:11011 CRENSHAW BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-6330
Mailing Address - Country:US
Mailing Address - Phone:310-677-7080
Mailing Address - Fax:866-894-5431
Practice Address - Street 1:11011 CRENSHAW BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-6330
Practice Address - Country:US
Practice Address - Phone:310-677-7080
Practice Address - Fax:866-894-5431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty