Healthcare Provider Details

I. General information

NPI: 1063761963
Provider Name (Legal Business Name): LOK TAM LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 01/14/2022
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 N GRAND AVE
COVINA CA
91724-1551
US

IV. Provider business mailing address

1126 N GRAND AVE
COVINA CA
91724-1551
US

V. Phone/Fax

Practice location:
  • Phone: 626-967-1667
  • Fax: 626-967-6027
Mailing address:
  • Phone: 626-967-1667
  • Fax: 626-967-6027

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 Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW90519
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: