MEDICARE: THESPACEBETWEENCOUNSELINGSERVICESLICENSEDCLINICALSOCIALWORKERINC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1457948077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THESPACEBETWEENCOUNSELINGSERVICESLICENSEDCLINICALSOCIALWORKERINC

Provider Business Mailing Address
First Line	:	12139 MOUNT VERNON AVE STE 200A
Second Line	:
City	:	GRAND TERRACE
State	:	CA
Zip	:	92313-5547
Country	:	US
Telephone Number	:	951-465-5812
Fax Number	:	951-346-5680

Provider Business Practice Location Address
First Line	:	12139 MOUNT VERNON AVE STE 200A
Second Line	:
City	:	GRAND TERRACE
State	:	CA
Zip	:	92313-5547
Country	:	US
Telephone Number	:	951-465-5812
Fax Number	:	951-346-5680

Authorized Official
Title or Position	:	LCSW
Name	:	MRS. ZUELIKA C XICOTENCATL
Credential	:	LCSW
Telephone Number	:	951-465-5812

Provider Enumeration Date	:	12/29/2020
Last Update Date	:	12/29/2020

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