Provider Demographics
NPI:1881233047
Name:EMBLAZE FAMILY THERAPY INC
Entity Type:Organization
Organization Name:EMBLAZE FAMILY THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:323-495-6521
Mailing Address - Street 1:PO BOX 3228
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-1428
Mailing Address - Country:US
Mailing Address - Phone:818-751-2008
Mailing Address - Fax:866-219-1310
Practice Address - Street 1:16300 CRENSHAW BLVD STE 208C
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90504-1441
Practice Address - Country:US
Practice Address - Phone:818-751-2008
Practice Address - Fax:866-219-1310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-04
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty