Provider Demographics
NPI:1003002593
Name:CLINICAL SOCIAL WORK SERVICES
Entity Type:Organization
Organization Name:CLINICAL SOCIAL WORK SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:JO
Authorized Official - Last Name:BOURG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:409-724-1920
Mailing Address - Street 1:3005 AVENUE H
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-7607
Mailing Address - Country:US
Mailing Address - Phone:409-724-1920
Mailing Address - Fax:409-724-1102
Practice Address - Street 1:3005 AVENUE H
Practice Address - Street 2:
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-7607
Practice Address - Country:US
Practice Address - Phone:409-724-1920
Practice Address - Fax:409-724-1102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0021AWMedicare PIN