=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851405377
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADRIANN DIMITRA PEMBERTON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2006
-----------------------------------------------------
Last Update Date | 05/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4951 ARROYO RD BUILDING 62, ROOM 505
-----------------------------------------------------
City | LIVERMORE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94550-9650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-373-4700
-----------------------------------------------------
Fax | 925-449-6541
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1640 25TH AVE
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94601-1009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-403-1349
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | MSW004060
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW004212
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------