1356141154 NPI number — CEREBRUM EXPLORATION COUNSELING, LICENSED CLINICAL SOCIAL WORKER CORP

Table of content: (NPI 1356141154)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356141154 NPI number — CEREBRUM EXPLORATION COUNSELING, LICENSED CLINICAL SOCIAL WORKER CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEREBRUM EXPLORATION COUNSELING, LICENSED CLINICAL SOCIAL WORKER CORP
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:
6
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:
1356141154
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2102 BUSINESS CENTER DR # 2010
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92612-1001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-445-0952
Provider Business Mailing Address Fax Number:
949-209-4965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23161 MILL CREEK DR STE 315
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGUNA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92653-7907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-445-0952
Provider Business Practice Location Address Fax Number:
949-368-9843
Provider Enumeration Date:
03/19/2025

Additional Information

Authorized Official

Authorized Official Last Name:
NEWBURY
Authorized Official First Name:
GLADYS
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
818-445-0952

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)

  • Identifier: 1164174710 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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