Provider Demographics
NPI:1508840752
Name:ZUCKERWISE, RICHARD AVRAM (PHD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:AVRAM
Last Name:ZUCKERWISE
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21243 VENTURA BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-2123
Mailing Address - Country:US
Mailing Address - Phone:818-999-6452
Mailing Address - Fax:818-999-5912
Practice Address - Street 1:21243 VENTURA BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2123
Practice Address - Country:US
Practice Address - Phone:818-999-6452
Practice Address - Fax:818-999-5912
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 10021104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3097332Medicaid
CAR37530Medicare ID - Type Unspecified