Provider Demographics
NPI:1477137933
Name:PACIFIC WELLNESS GROUP A PROFESSIONAL MARRIAGE & FAMILY THERAPY CORP
Entity Type:Organization
Organization Name:PACIFIC WELLNESS GROUP A PROFESSIONAL MARRIAGE & FAMILY THERAPY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEVINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MA LMFT
Authorized Official - Phone:424-436-1872
Mailing Address - Street 1:2716 OCEAN PARK BLVD STE 3075
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-5232
Mailing Address - Country:US
Mailing Address - Phone:424-436-1872
Mailing Address - Fax:424-416-7478
Practice Address - Street 1:2716 OCEAN PARK BLVD STE 3075
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-5232
Practice Address - Country:US
Practice Address - Phone:424-436-1872
Practice Address - Fax:424-416-7478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-11
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)