Healthcare Provider Details

I. General information

NPI: 1376965186
Provider Name (Legal Business Name): MARY CORSINA FIUMARA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 3RD ST
SANTA ROSA CA
95404-4501
US

IV. Provider business mailing address

811 3RD ST
SANTA ROSA CA
95404-4501
US

V. Phone/Fax

Practice location:
  • Phone: 707-236-2894
  • Fax:
Mailing address:
  • Phone: 707-236-2894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 24929
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: