Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | LCS20247 | CA |
NPI | 1003260845 |
---|---|
Provider Name | Tim Ross |
First Address | Morro Bay, CA 93442-2417 |
Second Address | Morro Bay, CA 93442-2417 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/04/2016 |
Last Update Date | 18/04/2016 |