Provider Demographics
NPI:1043030174
Name:SEA GLASS THERAPY AND WELLNESS LLC
Entity type:Organization
Organization Name:SEA GLASS THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAYLYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:901-326-3815
Mailing Address - Street 1:1692 MANGROVE AVE # 137
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-2648
Mailing Address - Country:US
Mailing Address - Phone:405-451-5330
Mailing Address - Fax:
Practice Address - Street 1:3359 PENZANCE AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-9683
Practice Address - Country:US
Practice Address - Phone:405-451-5330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health