=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518695709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HORN OPTIMAL WELLNESS SERVICES, INC. - A PROFESSIONAL LCSW CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2022
-----------------------------------------------------
Last Update Date | 08/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 MOUNT VERNON AVE
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94112-2424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-545-9019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1728 OCEAN AVE # 306
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94112-1737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-545-9019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MRS. COLETTE A REID-HORN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 510-545-9019
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------