Basic Information
| Provider Information | |||||||||
| NPI: | 1730759796 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNRISE THERAPY CENTER(STC) MARRIAGE FAMILY AND CHILD COUNSELING, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2648 E WORKMAN AVE # 3001-214 | ||||||||
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| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917911604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267882024 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 FREMONT AVE STE 101 | ||||||||
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| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910305704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267882024 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2021 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | ROBINSON SELWA | ||||||||
| AuthorizedOfficialFirstName: | AKIAH | ||||||||
| AuthorizedOfficialMiddleName: | TENEE' | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6267882024 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMFT | ||||||||
| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.