Provider Demographics
NPI:1417577792
Name:BRIAN SEAN STILLER LICENSED CLINICAL SOCIAL WORKER INC
Entity Type:Organization
Organization Name:BRIAN SEAN STILLER LICENSED CLINICAL SOCIAL WORKER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:SEAN
Authorized Official - Last Name:STILLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:858-215-4044
Mailing Address - Street 1:1367 E GOSHEN AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2648
Mailing Address - Country:US
Mailing Address - Phone:903-246-1953
Mailing Address - Fax:
Practice Address - Street 1:11622 EL CAMINO REAL STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2051
Practice Address - Country:US
Practice Address - Phone:858-215-4044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-16
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty