Provider Demographics
NPI:1447671334
Name:USC-TELEHEALTH
Entity type:Organization
Organization Name:USC-TELEHEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOTHERAPIST, INTERN
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-256-6488
Mailing Address - Street 1:17202 INGLEWOOD AVE
Mailing Address - Street 2:UNIT 122
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-3139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3375 S HOOVER ST
Practice Address - Street 2:SUITE H201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0116
Practice Address - Country:US
Practice Address - Phone:213-821-5930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty