Provider Demographics
NPI:1215033998
Name:LACOVARA, DOMINICK JOSEPH (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DOMINICK
Middle Name:JOSEPH
Last Name:LACOVARA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11549 LOS OSOS VALLEY RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-6471
Mailing Address - Country:US
Mailing Address - Phone:805-543-7040
Mailing Address - Fax:805-543-7015
Practice Address - Street 1:11549 LOS OSOS VALLEY RD
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-6471
Practice Address - Country:US
Practice Address - Phone:805-543-7040
Practice Address - Fax:805-543-7015
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS67451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R38033Medicare UPIN