Provider Demographics
NPI:1780830513
Name:RESNIKOFF, DAVID ALAN (LCS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALAN
Last Name:RESNIKOFF
Suffix:
Gender:M
Credentials:LCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 514
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95061-0514
Mailing Address - Country:US
Mailing Address - Phone:831-471-5044
Mailing Address - Fax:
Practice Address - Street 1:2901 PARK AVE
Practice Address - Street 2:STE B8
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2831
Practice Address - Country:US
Practice Address - Phone:831-471-5044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 246871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS 24687OtherPROFESSIONAL LICENSE