Healthcare Provider Details

I. General information

NPI: 1710207386
Provider Name (Legal Business Name): MAUDISA MAGONA MEROE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2081 CENTER ST
BERKELEY CA
94704-1204
US

IV. Provider business mailing address

2081 CENTER ST
BERKELEY CA
94704-1204
US

V. Phone/Fax

Practice location:
  • Phone: 323-705-3656
  • Fax:
Mailing address:
  • Phone: 323-705-3656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21862
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60301219
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1303431-SUPV
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC002370
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number09928588
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: