MEDICARE: FAMILY SERVICE AGENCY OF SAN MATEO COUNTY

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	LCSW	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ398386507010856	OTHER	CA	UNSURE

General Provider Information

NPI Number	:	1669406815
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY SERVICE AGENCY OF SAN MATEO COUNTY

Provider Business Mailing Address
First Line	:	24 2ND AVE
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94401-3828
Country	:	US
Telephone Number	:	650-403-4300
Fax Number	:	650-403-4305

Provider Business Practice Location Address
First Line	:	2600 MIDDLEFIELD RD
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94063-3402
Country	:	US
Telephone Number	:	650-780-7541
Fax Number	:	650-701-0856

Authorized Official
Title or Position	:	AGENCY PRESIDENT
Name	:	MS. LAURIE WISHARD
Credential	:	MSW
Telephone Number	:	650-403-4300

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	08/22/2020

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