Basic Information
| Provider Information | |||||||||
| NPI: | 1700072717 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JANICE DERDERIAN LICENSED CLINICAL SOCIAL WORKER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2685 | ||||||||
| Address2: | |||||||||
| City: | SEAL BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907401685 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1661 GOLDEN RAIN RD | ||||||||
| Address2: | |||||||||
| City: | SEAL BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907404907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5627956300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2007 | ||||||||
| LastUpdateDate: | 09/24/2007 | ||||||||
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| AuthorizedOfficialLastName: | DERDERIAN | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5627956300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW7388 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.