Healthcare Provider Details

I. General information

NPI: 1740974641
Provider Name (Legal Business Name): IDA CAO ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31351 RANCHO VIEJO RD STE 201
SAN JUAN CAPISTRANO CA
92675-1858
US

IV. Provider business mailing address

31351 RANCHO VIEJO RD STE 201
SAN JUAN CAPISTRANO CA
92675-1858
US

V. Phone/Fax

Practice location:
  • Phone: 949-240-2030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW125153
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: