Provider Demographics
NPI:1417334384
Name:SEBALD, EMILY ROSE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:ROSE
Last Name:SEBALD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:EMILY
Other - Middle Name:ROSE
Other - Last Name:MOHAMED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3105 UPSHUR AVE APT D
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-9459
Mailing Address - Country:US
Mailing Address - Phone:858-223-7105
Mailing Address - Fax:858-223-7109
Practice Address - Street 1:1145 STURGIS RD.
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278
Practice Address - Country:US
Practice Address - Phone:760-830-2752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA881421041C0700X
CA72195101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health