Provider Demographics
NPI:1114432762
Name:ENRICHED LIFE THERAPY CENTER
Entity Type:Organization
Organization Name:ENRICHED LIFE THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:213-441-6780
Mailing Address - Street 1:4221 WILSHIRE BLVD STE 290-26
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3540
Mailing Address - Country:US
Mailing Address - Phone:213-441-6780
Mailing Address - Fax:
Practice Address - Street 1:4221 WILSHIRE BLVD STE 290-26
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3540
Practice Address - Country:US
Practice Address - Phone:213-441-6780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 106H00000X
CA285821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty