Basic Information
| Provider Information | |||||||||
| NPI: | 1649944430 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WINGS OF THE FUTURE PRIVATE PRACTICE LICENSED CLINICAL WORKER PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WINGS OF THE FUTURE CONSULTING PRIVATE PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 LAKES DR STE 225 | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917902910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6614021545 | ||||||||
| FaxNumber: | 6617270006 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 LAKES DR STE 225 | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917902910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6614021545 | ||||||||
| FaxNumber: | 6617270006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2021 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOOTHE | ||||||||
| AuthorizedOfficialFirstName: | KRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6614021545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 83-2422898 | 01 | CA | IRS | OTHER |