=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932062197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OMNI CORE BEHAVIORAL HEALTH LCSW THERAPY AND CONSULTATION, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2025
-----------------------------------------------------
Last Update Date | 12/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 MARIAH PL
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95409-2692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-219-7125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5632 VAN NUYS BLVD UNIT 3193
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91401-4602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-219-7125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KONSTANCE CASTLE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 301-640-1116
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------