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NPI Code Detail

MEDICARE: EILEEN COLORADO LICENSEDCLINICAL SOCIALWORKER PROFESSIONAL CORPORATION

MEDICARE: EILEEN COLORADO LICENSEDCLINICAL SOCIALWORKER PROFESSIONAL CORPORATION
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
11041C0700XClinical Social Worker

General Provider Information

NPI Number : 1669038642
Entity Type Code : Organization
Provider Name (Legal Business Name) : EILEEN COLORADO LICENSEDCLINICAL SOCIALWORKER PROFESSIONAL CORPORATION
Provider Business Mailing Address
First Line : 1067 RIDGE PARK DR
Second Line :
City : CONCORD
State : CA
Zip : 94518-1434
Country : US
Telephone Number : 702-241-1249
Fax Number :
Provider Business Practice Location Address
First Line : 1300 CLAY ST STE 600
Second Line :
City : OAKLAND
State : CA
Zip : 94612-1427
Country : US
Telephone Number : 702-241-1249
Fax Number :
Authorized Official
Title or Position : OWNER
Name : EILEEN ELLSWORTH COLORADO
Credential : LCSW
Telephone Number : 702-241-1249
Provider Enumeration Date : 05/14/2019
Last Update Date : 05/14/2019

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