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12139 Mount Vernon Ave Ste 105 Grand Terrace CA 92313-5500 | |
| (951) 903-8022 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Social Worker |
| Location | 12139 Mount Vernon Ave Ste 105, Grand Terrace, California |
| Authorized Official Name and Position | Kalisha Koran Ayisha Brown (OWNER) |
| Authorized Official Contact | 9519038022 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
12139 Mount Vernon Ave Ste 105 Grand Terrace CA 92313-5500 Ph: (951) 903-8022 | 12139 Mount Vernon Ave Ste 105 Grand Terrace CA 92313-5500 Ph: (951) 903-8022 |
| NPI Number | 1972284958 |
|---|---|
| Provider Enumeration Date | 07/31/2023 |
| Last Update Date | 01/08/2025 |
| Certification Date | 01/08/2025 |
| Medicare PECOS PAC ID | 4082078027 |
|---|---|
| Medicare Enrollment ID | O20230911000920 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1972284958 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Secondary |
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Primary |
| Provider Name | Kalisha Koran Ayisha Brown |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1396307070 PECOS PAC ID: 7012313133 Enrollment ID: I20210914003840 |
Thespacebetweencounselingserviceslicensedclinicalsocialworkerinc Mental Health Clinic Medicare: Not Enrolled in Medicare Practice Location: 12139 Mount Vernon Ave Ste 200a, Grand Terrace, CA 92313 Phone: 951-465-5812 Fax: 951-346-5680 | |
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