Provider Demographics
NPI:1639658016
Name:INDIGENOUS CIRCLE OF WELLNESS; INDIVIDUAL, COUPLE, FAMILY COUNSELING
Entity Type:Organization
Organization Name:INDIGENOUS CIRCLE OF WELLNESS; INDIVIDUAL, COUPLE, FAMILY COUNSELING
Other - Org Name:INDIGENOUS CIRCLE OF WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTRO
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:626-782-5570
Mailing Address - Street 1:PO BOX 911484
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90091-1239
Mailing Address - Country:US
Mailing Address - Phone:323-629-4160
Mailing Address - Fax:
Practice Address - Street 1:5800 S EASTERN AVE STE 260
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040-4019
Practice Address - Country:US
Practice Address - Phone:626-782-5570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-07
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103TP2701X
CA104427106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty