Healthcare Provider Details

I. General information

NPI: 1427628247
Provider Name (Legal Business Name): LILLIE AVETISYAN-HARVEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 NEWPORT BLVD STE 110
COSTA MESA CA
92627-7762
US

IV. Provider business mailing address

1640 NEWPORT BLVD STE 110
COSTA MESA CA
92627-7762
US

V. Phone/Fax

Practice location:
  • Phone: 925-282-1778
  • Fax:
Mailing address:
  • Phone: 925-282-1778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number100984
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: