Provider Demographics
NPI:1689891327
Name:STERN, DIVORA WILMA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DIVORA
Middle Name:WILMA
Last Name:STERN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5975 TARTAR CANYON RD
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-9203
Mailing Address - Country:US
Mailing Address - Phone:707-459-9052
Mailing Address - Fax:707-459-9052
Practice Address - Street 1:175 S HUMBOLDT ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-3511
Practice Address - Country:US
Practice Address - Phone:707-354-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA204981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ27882ZMedicare ID - Type UnspecifiedMEDICARE PART B PROVIDER