Healthcare Provider Details

I. General information

NPI: 1508456740
Provider Name (Legal Business Name): AMR A LICENSED CLINICAL SOCIAL WORKER CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 GRAND AVE UNIT 201
LONG BEACH CA
90803-6179
US

IV. Provider business mailing address

262 LINDERO AVE
LONG BEACH CA
90803-5724
US

V. Phone/Fax

Practice location:
  • Phone: 530-637-8678
  • Fax:
Mailing address:
  • Phone: 562-253-2572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. ANN MARIE RUSSO
Title or Position: OWNER
Credential: LCSW
Phone: 323-207-5901