Healthcare Provider Details

I. General information

NPI: 1629150628
Provider Name (Legal Business Name): LYNNE MICHELLE DACOSTA L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1627 S HARGRAVE ST
BANNING CA
92220-6169
US

IV. Provider business mailing address

2085 RUSTIN AVE STE 1
RIVERSIDE CA
92507-2498
US

V. Phone/Fax

Practice location:
  • Phone: 951-922-7840
  • Fax: 951-922-7752
Mailing address:
  • Phone: 951-955-7320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21205
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: