Provider Demographics
NPI:1992179360
Name:A NEW CREATION CHILD, INDIVIDUAL & FAMILY COUNSELING TREATMENT CENTER
Entity Type:Organization
Organization Name:A NEW CREATION CHILD, INDIVIDUAL & FAMILY COUNSELING TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:310-963-7174
Mailing Address - Street 1:23800 SUNNYMEAD BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-7731
Mailing Address - Country:US
Mailing Address - Phone:310-963-7174
Mailing Address - Fax:888-313-0140
Practice Address - Street 1:23800 SUNNYMEAD BLVD STE D
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-7731
Practice Address - Country:US
Practice Address - Phone:310-420-5341
Practice Address - Fax:888-313-0140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-22
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT 49399261QM0801X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)