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General NPI Number Information
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NPI Number | 1740779164
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Entity Type | Organization
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Legal Business Name | SOURCE THERAPY LICENSED CLINICAL SOCIAL WORKER SERVICES APC
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Dates
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Enumeration Date | 05/02/2018
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Last Update Date | 02/17/2023
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Provider Practice Location Address
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Address Line | 1582 W SAN MARCOS BLVD STE 105
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City | SAN MARCOS
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State | CA
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Zip | 92078-4081
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Country | US
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Telephone | 760-522-7158
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Fax | 760-539-7357
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Provider Business Mailing Address
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Address Line | 1582 W SAN MARCOS BLVD STE 105
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City | SAN MARCOS
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State | CA
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Zip | 92078-4081
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Country | US
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Telephone | 760-522-7158
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Fax | 760-539-7357
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | CAROLYN BOWE-MCLEOD
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Credential |
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Telephone | 760-433-7944
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 27130
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License Number State | CA
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