Provider Demographics
NPI:1205111408
Name:FEDERICO, DINO RAY (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:DINO
Middle Name:RAY
Last Name:FEDERICO
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2575 SOUTH STEELE ROAD
Mailing Address - Street 2:#130
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3978
Mailing Address - Country:US
Mailing Address - Phone:909-659-6715
Mailing Address - Fax:
Practice Address - Street 1:2575 STEELE RD
Practice Address - Street 2:#130
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3950
Practice Address - Country:US
Practice Address - Phone:909-659-6715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS20964104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker