Provider Demographics
NPI:1194481556
Name:WINGS OF THE FUTURE, NFP
Entity type:Organization
Organization Name:WINGS OF THE FUTURE, NFP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BOOTHE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:661-402-1545
Mailing Address - Street 1:851 S SUNSET AVE APT 119
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-5546
Mailing Address - Country:US
Mailing Address - Phone:310-621-0150
Mailing Address - Fax:661-727-0006
Practice Address - Street 1:155 N LAKE AVE FL 8
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1849
Practice Address - Country:US
Practice Address - Phone:661-402-1545
Practice Address - Fax:661-727-0006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-10
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB394408OtherMEDICARE