Provider Demographics
NPI:1710388749
Name:STEVE DEITELBAUM, LICENSED CLINICAL SOCIAL WORKER, INC.
Entity Type:Organization
Organization Name:STEVE DEITELBAUM, LICENSED CLINICAL SOCIAL WORKER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEITELBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:310-473-4300
Mailing Address - Street 1:11500 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1524
Mailing Address - Country:US
Mailing Address - Phone:310-473-4300
Mailing Address - Fax:310-478-6698
Practice Address - Street 1:11500 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1524
Practice Address - Country:US
Practice Address - Phone:310-473-4300
Practice Address - Fax:310-478-6698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS14749A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASW14749AMedicare PIN