Provider Demographics
NPI:1346992500
Name:THERAPY MISSION LICENSED CLINICAL SOCIAL WORKER PC
Entity Type:Organization
Organization Name:THERAPY MISSION LICENSED CLINICAL SOCIAL WORKER PC
Other - Org Name:THERAPY MISSION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:REINA
Authorized Official - Middle Name:
Authorized Official - Last Name:AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:626-714-0011
Mailing Address - Street 1:554 E FOOTHILL BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1222
Mailing Address - Country:US
Mailing Address - Phone:626-714-0011
Mailing Address - Fax:
Practice Address - Street 1:554 E FOOTHILL BLVD STE 106
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1222
Practice Address - Country:US
Practice Address - Phone:626-714-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-19
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)