Provider Demographics
NPI:1639293574
Name:WELLNEST EMOTIONAL HEALTH & WELLNESS
Entity Type:Organization
Organization Name:WELLNEST EMOTIONAL HEALTH & WELLNESS
Other - Org Name:WELLNEST - LEIMERT PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HIRSCH MARIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-372-2400
Mailing Address - Street 1:3031 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-3033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4401 CRENSHAW BLVD STE 300
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-1227
Practice Address - Country:US
Practice Address - Phone:323-290-8360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-17
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No252Y00000XAgenciesEarly Intervention Provider Agency
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACT052192Medicaid