Provider Demographics
NPI:1770365975
Name:ELEVATE PSYCHOLOGY AND WELLNESS
Entity type:Organization
Organization Name:ELEVATE PSYCHOLOGY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-564-6170
Mailing Address - Street 1:1007 N SEPULVEDA BLVD UNIT 212
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90267-8208
Mailing Address - Country:US
Mailing Address - Phone:310-564-6170
Mailing Address - Fax:
Practice Address - Street 1:3608 MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-3234
Practice Address - Country:US
Practice Address - Phone:310-564-6170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty