Provider Demographics
NPI:1396432951
Name:VICTORIA COMMUNITY COUNSELING LICENSED CLINICAL SOCIAL WORKER CO
Entity type:Organization
Organization Name:VICTORIA COMMUNITY COUNSELING LICENSED CLINICAL SOCIAL WORKER CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:951-476-5642
Mailing Address - Street 1:4181 FLAT ROCK DR STE 305&307
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-7103
Mailing Address - Country:US
Mailing Address - Phone:951-476-5642
Mailing Address - Fax:
Practice Address - Street 1:4181 FLAT ROCK DR
Practice Address - Street 2:STE 305 307
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-2971
Practice Address - Country:US
Practice Address - Phone:951-476-5642
Practice Address - Fax:833-672-3306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-21
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty