1669925459 NPI number — MR. GREGORY PETER PANDZIC LCSW

Table of content: MR. GREGORY PETER PANDZIC LCSW (NPI 1669925459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669925459 NPI number — MR. GREGORY PETER PANDZIC LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANDZIC
Provider First Name:
GREGORY
Provider Middle Name:
PETER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

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:
1669925459
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
235 OLIVE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLAREMONT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91711-4926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-917-3373
Provider Business Mailing Address Fax Number:
909-418-6937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
235 OLIVE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAREMONT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91711-4926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-917-3373
Provider Business Practice Location Address Fax Number:
909-418-6937
Provider Enumeration Date:
07/27/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LCSW105016 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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