=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972478170
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIERRA LUZ COMMUNITY PRACTICE, LICENSE CLINICAL SOCIAL WORKER, A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2025
-----------------------------------------------------
Last Update Date | 10/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 721 S A ST STE C
-----------------------------------------------------
City | OXNARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93030-7179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-767-9788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 93
-----------------------------------------------------
City | OXNARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93032-0093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-767-9788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | KATHLEEN JUDITH BACA LEANOS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 661-510-2423
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------