Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | LCS26201 | CA |
NPI | 1003174699 |
---|---|
Provider Name | Justin Sprague Weber |
First Address | Aliso Viejo, CA 92656-8079 |
Second Address | Aliso Viejo, CA 92656-8079 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/05/2012 |
Last Update Date | 02/05/2012 |