Provider Demographics
NPI:1144972654
Name:SUPPORTIVE SERVICES BY HOUSEAL, LICENSED CLINICAL SOCIAL WORKER INC.
Entity type:Organization
Organization Name:SUPPORTIVE SERVICES BY HOUSEAL, LICENSED CLINICAL SOCIAL WORKER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO AND PRESIDENT- LCSW
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:EDDIE
Authorized Official - Last Name:HOUSEAL
Authorized Official - Suffix:JR
Authorized Official - Credentials:LCSW
Authorized Official - Phone:302-668-6525
Mailing Address - Street 1:1050 LAKES DR STE 225
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2910
Mailing Address - Country:US
Mailing Address - Phone:626-699-0990
Mailing Address - Fax:
Practice Address - Street 1:1050 LAKES DR STE 225
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2910
Practice Address - Country:US
Practice Address - Phone:626-699-0990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-25
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100220OtherLCSW