=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063066439
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IGNACIO GARCIA GLUCKLICH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2019
-----------------------------------------------------
Last Update Date | 11/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2750 E WASHINGTON BLVD STE 230
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91107-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-296-8900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 WESTERLY TER
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90026-1234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-578-8018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 104088
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041S0200X
-----------------------------------------------------
Taxonomy Name | School Social Worker
-----------------------------------------------------
License Number | 104088
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 104088
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------