Provider Demographics
NPI:1366102337
Name:STILLWATER FAMILY THERAPY GROUP, INC.
Entity type:Organization
Organization Name:STILLWATER FAMILY THERAPY GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:310-378-2520
Mailing Address - Street 1:4727 W 164TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-2824
Mailing Address - Country:US
Mailing Address - Phone:310-378-2520
Mailing Address - Fax:
Practice Address - Street 1:4727 W 164TH ST
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-2824
Practice Address - Country:US
Practice Address - Phone:310-378-2520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
11702210OtherCAQH