Healthcare Provider Details

I. General information

NPI: 1942428842
Provider Name (Legal Business Name): PAUL J. KOFLANOVICH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 CALIFORNIA DRIVE
YOUNTVILLE CA
94599-1418
US

IV. Provider business mailing address

150 CALIFORNIA DRIVE
YOUNTVILLE CA
94599-1418
US

V. Phone/Fax

Practice location:
  • Phone: 707-944-4582
  • Fax: 707-944-4590
Mailing address:
  • Phone: 707-944-4582
  • Fax: 707-944-4590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 7886
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: