Provider Demographics
NPI:1356141154
Name:CEREBRUM EXPLORATION COUNSELING, LICENSED CLINICAL SOCIAL WORKER CORP
Entity type:Organization
Organization Name:CEREBRUM EXPLORATION COUNSELING, LICENSED CLINICAL SOCIAL WORKER CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:Y
Authorized Official - Last Name:NEWBURY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:818-445-0952
Mailing Address - Street 1:2102 BUSINESS CENTER DR # 2010
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-1001
Mailing Address - Country:US
Mailing Address - Phone:818-445-0952
Mailing Address - Fax:949-209-4965
Practice Address - Street 1:23161 MILL CREEK DR STE 315
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-7907
Practice Address - Country:US
Practice Address - Phone:818-445-0952
Practice Address - Fax:949-368-9843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-19
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1164174710Medicaid