Provider Demographics
NPI:1588248439
Name:A LIST THERAPY GROUP
Entity type:Organization
Organization Name:A LIST THERAPY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MINA
Authorized Official - Middle Name:S
Authorized Official - Last Name:HANNA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:909-262-8691
Mailing Address - Street 1:7125 AMETHYST AVE APT 2302
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-6451
Mailing Address - Country:US
Mailing Address - Phone:909-262-8691
Mailing Address - Fax:
Practice Address - Street 1:6677 SANTA MONICA BLVD APT 4616
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-1992
Practice Address - Country:US
Practice Address - Phone:323-943-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1619480126Medicaid