Provider Demographics
NPI:1710003660
Name:CONCELLOSI, JOSEPH M (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:M
Last Name:CONCELLOSI
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 KEMPER ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4903
Mailing Address - Country:US
Mailing Address - Phone:619-758-6205
Mailing Address - Fax:619-752-6209
Practice Address - Street 1:3320 KEMPER ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4903
Practice Address - Country:US
Practice Address - Phone:619-758-6205
Practice Address - Fax:619-752-6209
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS13561251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS13561OtherLCSW LICENSE