Healthcare Provider Details

I. General information

NPI: 1952966053
Provider Name (Legal Business Name): SHAUNEET MARDUK, LICENSE CLINICAL SOCIAL WORKER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2019
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25101 THE OLD RD STE 131
STEVENSON RANCH CA
91381-2206
US

IV. Provider business mailing address

PO BOX 5200
SHERMAN OAKS CA
91413-5200
US

V. Phone/Fax

Practice location:
  • Phone: 818-489-7137
  • Fax:
Mailing address:
  • Phone: 818-489-7137
  • Fax: 818-475-1646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MISS SHAUNEET EVE MARDUK
Title or Position: PRESIDENT
Credential: LCSW
Phone: 818-489-7137