MEDICARE: ALICIA MITTLEMAN LICENSED CLINICAL SOCIAL WORKER COUNSELING SERVICES

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	28794	CA

General Provider Information

NPI Number	:	1588171730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALICIA MITTLEMAN LICENSED CLINICAL SOCIAL WORKER COUNSELING SERVICES

Provider Business Mailing Address
First Line	:	3880 FOWLER RD
Second Line	:
City	:	WEST SACRAMENTO
State	:	CA
Zip	:	95691-5491
Country	:	US
Telephone Number	:	916-425-7733
Fax Number	:

Provider Business Practice Location Address
First Line	:	3880 FOWLER RD
Second Line	:
City	:	WEST SACRAMENTO
State	:	CA
Zip	:	95691-5491
Country	:	US
Telephone Number	:	916-425-7733
Fax Number	:	916-372-2466

Authorized Official
Title or Position	:	CEO
Name	:	ALICIA LAUREL MITTLEMAN
Credential	:	LCSW
Telephone Number	:	916-425-7733

Provider Enumeration Date	:	01/09/2018
Last Update Date	:	02/13/2023

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