Provider Demographics
NPI:1477895431
Name:LIVE FORWARD PSYCHOLOGICAL INC
Entity Type:Organization
Organization Name:LIVE FORWARD PSYCHOLOGICAL INC
Other - Org Name:THE WELL MIND INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNICE
Authorized Official - Middle Name:
Authorized Official - Last Name:VILHAUER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-362-6769
Mailing Address - Street 1:PO BOX 461525
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-9525
Mailing Address - Country:US
Mailing Address - Phone:310-362-6769
Mailing Address - Fax:
Practice Address - Street 1:201 N ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1729
Practice Address - Country:US
Practice Address - Phone:310-362-6769
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-17
Last Update Date:2013-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20105103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty