Provider Demographics
NPI:1942428842
Name:KOFLANOVICH, PAUL J (LCSW)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:KOFLANOVICH
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 1:150 CALIFORNIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:YOUNTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94599-1418
Mailing Address - Country:US
Mailing Address - Phone:707-944-4582
Mailing Address - Fax:707-944-4590
Practice Address - Street 1:150 CALIFORNIA DRIVE
Practice Address - Street 2:
Practice Address - City:YOUNTVILLE
Practice Address - State:CA
Practice Address - Zip Code:94599-1418
Practice Address - Country:US
Practice Address - Phone:707-944-4582
Practice Address - Fax:707-944-4590
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 78861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ17383Medicare UPIN