MEDICARE: MRS. TONYA D. OCTAVE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	25108	CA

General Provider Information

NPI Number	:	1518191253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TONYA D. OCTAVE LCSW

Provider Business Mailing Address
First Line	:	237 S LAKEVIEW AVE STE A
Second Line	:
City	:	PLACENTIA
State	:	CA
Zip	:	92870-6756
Country	:	US
Telephone Number	:	310-387-8164
Fax Number	:

Provider Business Practice Location Address
First Line	:	9778 KATELLA AVE STE 109D
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92804-6446
Country	:	US
Telephone Number	:	310-387-8164
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2009
Last Update Date	:	08/02/2019

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