Healthcare Provider Details

I. General information

NPI: 1558828905
Provider Name (Legal Business Name): MARIA CARMEN FIDUK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17800 WOODRUFF AVE
BELLFLOWER CA
90706-7079
US

IV. Provider business mailing address

PO BOX 1592
PORT ORCHARD WA
98366-0150
US

V. Phone/Fax

Practice location:
  • Phone: 562-866-8500
  • Fax:
Mailing address:
  • Phone: 323-366-7812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103931
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: