Healthcare Provider Details

I. General information

NPI: 1043704331
Provider Name (Legal Business Name): CENTRAL COUNSELING SERVICES LICENSED CLINICAL SOCIAL WORKER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6840 INDIANA AVE STE 275
RIVERSIDE CA
92506-4279
US

IV. Provider business mailing address

6840 INDIANA AVE STE 275
RIVERSIDE CA
92506-4279
US

V. Phone/Fax

Practice location:
  • Phone: 951-778-0230
  • Fax:
Mailing address:
  • Phone: 951-778-0230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26872
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number37209
License Number StateCA

VIII. Authorized Official

Name: SHERALYN L. SHOCKEY-POPE
Title or Position: CHIEF OPERATION OFFICER
Credential: LMFT
Phone: 951-778-0230