Healthcare Provider Details

I. General information

NPI: 1881103398
Provider Name (Legal Business Name): THERA FRENTZ STORM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIR
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

334 MAINSAIL RD
OCEANSIDE CA
92054-4605
US

V. Phone/Fax

Practice location:
  • Phone: 910-547-7744
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904009246
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: