Provider Demographics
NPI:1174244263
Name:CHILD & INDIVIDUAL ART THERAPY
Entity type:Organization
Organization Name:CHILD & INDIVIDUAL ART THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVANAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, ATR
Authorized Official - Phone:424-247-6010
Mailing Address - Street 1:2401 PACIFIC COAST HWY STE 106
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-2734
Mailing Address - Country:US
Mailing Address - Phone:424-247-6010
Mailing Address - Fax:
Practice Address - Street 1:2401 PACIFIC COAST HWY STE 106
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2734
Practice Address - Country:US
Practice Address - Phone:424-247-6010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-07
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty