Healthcare Provider Details

I. General information

NPI: 1699545616
Provider Name (Legal Business Name): SUGI Y KOMAROV MSW, CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2024
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 OCASO ST
RANCHO MISSION VIEJO CA
92694-1601
US

IV. Provider business mailing address

10 OCASO ST
RANCHO MISSION VIEJO CA
92694-1601
US

V. Phone/Fax

Practice location:
  • Phone: 214-641-3366
  • Fax: 949-388-1989
Mailing address:
  • Phone: 214-641-3366
  • Fax: 949-388-1989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: