Provider Demographics
NPI:1659144939
Name:POPPY THERAPY, A LICENSED CLINICAL SOCIAL WORKER PC
Entity Type:Organization
Organization Name:POPPY THERAPY, A LICENSED CLINICAL SOCIAL WORKER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:VASA BERTOLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:510-289-0215
Mailing Address - Street 1:3045 RUTGERS AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-3529
Mailing Address - Country:US
Mailing Address - Phone:510-289-0215
Mailing Address - Fax:
Practice Address - Street 1:5152 KATELLA AVE STE 205
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2846
Practice Address - Country:US
Practice Address - Phone:510-289-0215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty