=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841153871
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISLAND MENTAL HEALTH SERVICES LICENSED CLINICAL SOCIAL WORKER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2025
-----------------------------------------------------
Last Update Date | 12/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2881 MEADOW DR
-----------------------------------------------------
City | LAKEPORT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95453-9616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-510-9330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2881 MEADOW DR
-----------------------------------------------------
City | LAKEPORT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95453-9616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-510-9330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LAYLA HAYES
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 707-510-9330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------