Provider Demographics
NPI:1730229162
Name:RICHARD, MINDY LEE (LCSW)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:LEE
Last Name:RICHARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:951-324-5901
Mailing Address - Fax:877-778-9472
Practice Address - Street 1:5549 VAN BUREN BLVD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-2068
Practice Address - Country:US
Practice Address - Phone:951-324-5901
Practice Address - Fax:877-778-9472
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CALCSW61077104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health