Provider Demographics
NPI:1457449670
Name:MIJUSKOVIC, BEN LAZARE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BEN
Middle Name:LAZARE
Last Name:MIJUSKOVIC
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:BEN
Other - Middle Name:LAZARE
Other - Last Name:MIJUSKOVIC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:428 CARNATION AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-2843
Mailing Address - Country:US
Mailing Address - Phone:949-675-7332
Mailing Address - Fax:
Practice Address - Street 1:17707 STUDEBAKER RD
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2640
Practice Address - Country:US
Practice Address - Phone:562-402-0688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS165491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical