Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 104100000X | Social Worker | 79694 | CA |
Y | 1041C0700X | Clinical Social Worker | LCSW100125 | CA |
NPI | 1003266578 |
---|---|
Provider Name | Avian Weiswerda |
First Address | Los Angeles, CA 90021-1026 |
Second Address | Los Angeles, CA 90021-1026 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2016 |
Last Update Date | 30/07/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1041C0700 | (05) | CA |