Healthcare Provider Details

I. General information

NPI: 1366351066
Provider Name (Legal Business Name): SOUTH LAKE TAHOE THERAPY, LICENSED CLINICAL SOCIAL WORKER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2489 LAKE TAHOE BLVD STE 24
SOUTH LAKE TAHOE CA
96150-7739
US

IV. Provider business mailing address

2489 LAKE TAHOE BLVD STE 24
SOUTH LAKE TAHOE CA
96150-7739
US

V. Phone/Fax

Practice location:
  • Phone: 646-245-6169
  • Fax:
Mailing address:
  • Phone: 646-245-6169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MARTA TUZNIK
Title or Position: PRESIDENT
Credential: LCSW
Phone: 646-245-6169