Provider Demographics
NPI:1093571200
Name:BRAIN REPAIR THERAPY SERVICES LICENSED CLINICAL SOCIAL WORKER INC
Entity Type:Organization
Organization Name:BRAIN REPAIR THERAPY SERVICES LICENSED CLINICAL SOCIAL WORKER INC
Other - Org Name:BRAIN REPAIR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PLEIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:949-415-4204
Mailing Address - Street 1:PO BOX 1446
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92609-1446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23161 MILL CREEK DR STE 315
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-7907
Practice Address - Country:US
Practice Address - Phone:949-415-4204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-26
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty