Healthcare Provider Details

I. General information

NPI: 1063066439
Provider Name (Legal Business Name): IGNACIO GARCIA GLUCKLICH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 E WASHINGTON BLVD STE 230
PASADENA CA
91107-1449
US

IV. Provider business mailing address

1600 WESTERLY TER
LOS ANGELES CA
90026-1234
US

V. Phone/Fax

Practice location:
  • Phone: 626-296-8900
  • Fax:
Mailing address:
  • Phone: 323-578-8018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number104088
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number104088
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104088
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: