Healthcare Provider Details

I. General information

NPI: 1982182903
Provider Name (Legal Business Name): THERAPY IN A BAG, LICENSED CLINICAL SOCIAL WORKER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4164 BROCKTON AVE
RIVERSIDE CA
92501-3400
US

IV. Provider business mailing address

PO BOX 1403
RIVERSIDE CA
92502-1403
US

V. Phone/Fax

Practice location:
  • Phone: 951-347-6935
  • Fax: 951-346-9175
Mailing address:
  • Phone: 951-347-6935
  • Fax: 951-346-9175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA M DRYAN
Title or Position: PRESIDENT THERAPY IN A BAG, A LICEN
Credential: LCSW
Phone: 951-347-6935