Healthcare Provider Details

I. General information

NPI: 1114694338
Provider Name (Legal Business Name): KSENIA USTINOVA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3079 HARRISON AVE #12 #118
SOUTH LAKE TAHOE CA
96150
US

IV. Provider business mailing address

PO BOX 9683
SOUTH LAKE TAHOE CA
96158-2683
US

V. Phone/Fax

Practice location:
  • Phone: 530-447-0253
  • Fax:
Mailing address:
  • Phone: 916-248-9264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number138685
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: