Provider Demographics
NPI:1376780411
Name:DEGENNARO, MIMI (LCSW)
Entity type:Individual
Prefix:MS
First Name:MIMI
Middle Name:
Last Name:DEGENNARO
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 1:448 IGNACIO
Mailing Address - Street 2:#132
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949
Mailing Address - Country:US
Mailing Address - Phone:415-269-8989
Mailing Address - Fax:
Practice Address - Street 1:250 BEL MARIN KEYS
Practice Address - Street 2:C-1
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949
Practice Address - Country:US
Practice Address - Phone:415-369-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA187381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical