1104454966 NPI number — TTM LICENSED CLINICAL SOCIAL WORKER INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104454966 NPI number — TTM LICENSED CLINICAL SOCIAL WORKER INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TTM LICENSED CLINICAL SOCIAL WORKER INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104454966
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19360 RINALDI ST # 141
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTER RANCH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91326-1607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-490-1968
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16133 VENTURA BLVD STE 1125
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENCINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91436-2424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-522-6212
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/29/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MELENDEZ
Authorized Official First Name:
TATIANA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/ CEO
Authorized Official Telephone Number:
310-490-1968

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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