Basic Information
| Provider Information | |||||||||
| NPI: | 1821468851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTMAN | ||||||||
| FirstName: | SHIRLEY | ||||||||
| MiddleName: | IL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHUNG | ||||||||
| OtherFirstName: | SHIRLEY | ||||||||
| OtherMiddleName: | IL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LLMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1040 FLYNN RD | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930125092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056733930 | ||||||||
| FaxNumber: | 8056593217 | ||||||||
| Practice Location | |||||||||
| Address1: | 4279 TIERRA REJADA RD | ||||||||
| Address2: | |||||||||
| City: | MOORPARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930213775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052222326 | ||||||||
| FaxNumber: | 8052222333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2015 | ||||||||
| LastUpdateDate: | 02/07/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 76962 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.