Provider Demographics
NPI:1639504467
Name:SERENITY TRAUMA FOUNDATION
Entity Type:Organization
Organization Name:SERENITY TRAUMA FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAROL
Authorized Official - Middle Name:DARSA
Authorized Official - Last Name:NECHUSHTAN
Authorized Official - Suffix:
Authorized Official - Credentials:CLINICAL PSYCHOLOGIS
Authorized Official - Phone:310-310-9249
Mailing Address - Street 1:881 ALMA REAL DR STE 218
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-5039
Mailing Address - Country:US
Mailing Address - Phone:310-310-9249
Mailing Address - Fax:310-230-7440
Practice Address - Street 1:881 ALMA REAL DR STE 218
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-5039
Practice Address - Country:US
Practice Address - Phone:310-310-9249
Practice Address - Fax:310-230-7440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty