Provider Demographics
NPI:1740779164
Name:SOURCE THERAPY LICENSED CLINICAL SOCIAL WORKER SERVICES APC
Entity Type:Organization
Organization Name:SOURCE THERAPY LICENSED CLINICAL SOCIAL WORKER SERVICES APC
Other - Org Name:MICHELLE M. COLARUSSO, LCSW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWE-MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-433-7944
Mailing Address - Street 1:1582 W SAN MARCOS BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-4081
Mailing Address - Country:US
Mailing Address - Phone:760-522-7158
Mailing Address - Fax:760-539-7357
Practice Address - Street 1:1582 W SAN MARCOS BLVD STE 105
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-4081
Practice Address - Country:US
Practice Address - Phone:760-522-7158
Practice Address - Fax:760-539-7357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-02
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA271301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1568704807Medicaid