Healthcare Provider Details

I. General information

NPI: 1457449670
Provider Name (Legal Business Name): BEN LAZARE MIJUSKOVIC LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BEN LAZARE MIJUSKOVIC LCSW

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17707 STUDEBAKER RD
CERRITOS CA
90703-2640
US

IV. Provider business mailing address

428 CARNATION AVE
CORONA DEL MAR CA
92625-2843
US

V. Phone/Fax

Practice location:
  • Phone: 562-402-0688
  • Fax:
Mailing address:
  • Phone: 949-675-7332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS16549
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: