=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972934289
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TL LICENSED CLINICAL SOCIAL WORKER INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2013
-----------------------------------------------------
Last Update Date | 12/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2222 MARTIN SUITE 200
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92612-1458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-444-2851
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 61693
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-444-2851
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | JESSICA ERIN HAMILTON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 949-444-2851
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 29227
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------