Healthcare Provider Details

I. General information

NPI: 1023895802
Provider Name (Legal Business Name): ADRIANNE AVERBUKH A LICENSED CLINICAL SOCIAL WORKER CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1714 IVAR AVE # D
LOS ANGELES CA
90028-5124
US

IV. Provider business mailing address

1714 IVAR AVE # D
LOS ANGELES CA
90028-5124
US

V. Phone/Fax

Practice location:
  • Phone: 323-471-3212
  • Fax: 323-464-9161
Mailing address:
  • Phone: 323-471-3212
  • Fax: 323-464-9161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ADRIANNE AVERBUKH
Title or Position: CEO
Credential:
Phone: 323-200-4614