Provider Demographics
NPI:1447076690
Name:WONDERFUL COUNSELOR HOLISTIC PSYCHIATRIC CARE A PROFESSIONAL NU
Entity type:Organization
Organization Name:WONDERFUL COUNSELOR HOLISTIC PSYCHIATRIC CARE A PROFESSIONAL NU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:AHILA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTHAIYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-974-7347
Mailing Address - Street 1:4368 EAGLE ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-3211
Mailing Address - Country:US
Mailing Address - Phone:314-974-7347
Mailing Address - Fax:314-843-0201
Practice Address - Street 1:4368 EAGLE ROCK BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-3211
Practice Address - Country:US
Practice Address - Phone:314-974-7347
Practice Address - Fax:314-843-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-03
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty