Provider Demographics
NPI:1811202609
Name:KANTZAVELOS, PATRICIA CHRIS (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:CHRIS
Last Name:KANTZAVELOS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:CHRISTINA
Other - Middle Name:PATRICIA
Other - Last Name:KANTZAVELOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:4142 ADAMS AVE
Mailing Address - Street 2:UNIT 103-123
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-2592
Mailing Address - Country:US
Mailing Address - Phone:310-600-5479
Mailing Address - Fax:
Practice Address - Street 1:4142 ADAMS AVE
Practice Address - Street 2:UNIT 103-123
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-2592
Practice Address - Country:US
Practice Address - Phone:310-600-5479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-17
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA732711041C0700X
CAASW34305101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical