Provider Demographics
NPI:1063020717
Name:PHILLIP TARDANICO, LICENSED CLINICAL SOCIAL WORKER & ASSOCIATES, PC
Entity Type:Organization
Organization Name:PHILLIP TARDANICO, LICENSED CLINICAL SOCIAL WORKER & ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:TARDANICO
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:760-217-9527
Mailing Address - Street 1:15000 7TH STREET SUITE 201
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-2463
Mailing Address - Country:US
Mailing Address - Phone:760-217-9527
Mailing Address - Fax:
Practice Address - Street 1:15000 7TH ST STE 209
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3853
Practice Address - Country:US
Practice Address - Phone:760-217-9527
Practice Address - Fax:442-267-5623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-20
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA800682649Medicaid