=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861144941
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUDREY OU LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2022
-----------------------------------------------------
Last Update Date | 01/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 739 MAIN ST STE G
-----------------------------------------------------
City | PLEASANTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94566-6641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-402-2928
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5424 SUNOL BLVD. SUITE 10 #1013
-----------------------------------------------------
City | PLEASANTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94566-7705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-402-2928
-----------------------------------------------------
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 | 26831
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------