=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215854385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OMNILECTIC THERAPY COLLECTIVE, A LICENSED CLINICAL SOCIAL WORKER CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2026
-----------------------------------------------------
Last Update Date | 06/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14456 FOOTHILL BLVD UNIT 44
-----------------------------------------------------
City | SYLMAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91342-1535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-316-4707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14456 FOOTHILL BLVD UNIT 44
-----------------------------------------------------
City | SYLMAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91342-1535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-316-4707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARY TOBON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 714-316-4707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------