Healthcare Provider Details

I. General information

NPI: 1164598355
Provider Name (Legal Business Name): DENNIS BRENT IRVING LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17350 MOUNT HERRMANN ST SUITE A
FOUNTAIN VALLEY CA
92708-4114
US

IV. Provider business mailing address

2503 E PURITAN CIR
ANAHEIM CA
92806-4314
US

V. Phone/Fax

Practice location:
  • Phone: 714-444-3463
  • Fax: 714-444-1768
Mailing address:
  • Phone: 714-991-5414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 11053
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: