Provider Demographics
NPI:1093350910
Name:BEAM-LONGWELL, HEAVEN
Entity Type:Individual
Prefix:
First Name:HEAVEN
Middle Name:
Last Name:BEAM-LONGWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21825 ERWIN ST STE 1062
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-3610
Mailing Address - Country:US
Mailing Address - Phone:424-955-1595
Mailing Address - Fax:
Practice Address - Street 1:21550 OXNARD ST STE 200
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-7108
Practice Address - Country:US
Practice Address - Phone:855-701-7955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA144223106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist