Provider Demographics
NPI:1255454229
Name:CHETHIK, ISABEL DIANN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:ISABEL
Middle Name:DIANN
Last Name:CHETHIK
Suffix:
Gender:F
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:PO BOX 60575
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-0575
Mailing Address - Country:US
Mailing Address - Phone:650-328-0828
Mailing Address - Fax:
Practice Address - Street 1:1149 CHESTNUT ST
Practice Address - Street 2:#11
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4347
Practice Address - Country:US
Practice Address - Phone:650-328-0828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 60241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA157954OtherVALUE OPTIONS INSURANCE
CAIC3166746OtherUBH USER NAME