Provider Demographics
NPI:1417513458
Name:PAULA KETTULA LICENSED CLINICAL SOCIAL WORKER, INC.
Entity Type:Organization
Organization Name:PAULA KETTULA LICENSED CLINICAL SOCIAL WORKER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:KETTULA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:619-577-5057
Mailing Address - Street 1:1855 1ST AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2650
Mailing Address - Country:US
Mailing Address - Phone:619-577-5057
Mailing Address - Fax:619-324-1023
Practice Address - Street 1:1855 1ST AVE STE 103
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2650
Practice Address - Country:US
Practice Address - Phone:619-577-5057
Practice Address - Fax:619-324-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty