Provider Demographics
NPI:1376922328
Name:EPIPHANY COUNSELING, CONSULTING & TREATMENT SERVICES, PC
Entity type:Organization
Organization Name:EPIPHANY COUNSELING, CONSULTING & TREATMENT SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIYUME
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:424-570-6955
Mailing Address - Street 1:302 W 5TH ST STE 308
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2750
Mailing Address - Country:US
Mailing Address - Phone:424-570-6955
Mailing Address - Fax:424-363-1721
Practice Address - Street 1:302 W 5TH ST STE 308
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2750
Practice Address - Country:US
Practice Address - Phone:424-376-8705
Practice Address - Fax:424-363-1721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CALCSW645551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty