=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659144939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POPPY THERAPY, A LICENSED CLINICAL SOCIAL WORKER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2023
-----------------------------------------------------
Last Update Date | 10/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5152 KATELLA AVE STE 205
-----------------------------------------------------
City | LOS ALAMITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90720-2846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-289-0215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3045 RUTGERS AVE
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90808-3529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-289-0215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MOLLY VASA BERTOLUCCI
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 510-289-0215
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------