Provider Demographics
NPI:1972117133
Name:WISE WINGS FAMILY COUNSELING INCORPORATED
Entity Type:Organization
Organization Name:WISE WINGS FAMILY COUNSELING INCORPORATED
Other - Org Name:WISE WINGS COUNSELING LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:805-428-4722
Mailing Address - Street 1:30700 RUSSELL RANCH RD STE 250
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-9507
Mailing Address - Country:US
Mailing Address - Phone:805-390-4908
Mailing Address - Fax:
Practice Address - Street 1:141 DUESENBERG DR STE 15C
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-3478
Practice Address - Country:US
Practice Address - Phone:805-390-4908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-04
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty