Healthcare Provider Details

I. General information

NPI: 1801927868
Provider Name (Legal Business Name): AMY LUCILLE AVERWEG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 S GRAND AVE
GLENDORA CA
91740-5000
US

IV. Provider business mailing address

3182 TAMARACK WAY
MIRA LOMA CA
91752-2803
US

V. Phone/Fax

Practice location:
  • Phone: 626-335-5980
  • Fax:
Mailing address:
  • Phone: 626-318-7273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW20421
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 25260
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: