Provider Demographics
NPI:1235342973
Name:WINGS OF REFUGE
Entity Type:Organization
Organization Name:WINGS OF REFUGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-671-6767
Mailing Address - Street 1:5777 W CENTURY BLVD
Mailing Address - Street 2:SUITE 910
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5600
Mailing Address - Country:US
Mailing Address - Phone:310-670-6767
Mailing Address - Fax:310-670-2626
Practice Address - Street 1:5777 W CENTURY BLVD
Practice Address - Street 2:SUITE 910
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-5600
Practice Address - Country:US
Practice Address - Phone:310-670-6767
Practice Address - Fax:310-670-2626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty