Provider Demographics
NPI:1831692573
Name:THE PRACTICE COUNSELING SERVICES LICENSED CLINICAL SOCIAL WORKER, PC
Entity type:Organization
Organization Name:THE PRACTICE COUNSELING SERVICES LICENSED CLINICAL SOCIAL WORKER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMMARTINO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:562-587-7409
Mailing Address - Street 1:1000 TEXAS ST STE D
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-5700
Mailing Address - Country:US
Mailing Address - Phone:562-587-7409
Mailing Address - Fax:
Practice Address - Street 1:1000 TEXAS ST STE D
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533
Practice Address - Country:US
Practice Address - Phone:562-587-7409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-08
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA711871041C0700X
CA792561041C0700X
CA699291041C0700X
CA701761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty