Provider Demographics
NPI:1700072717
Name:JANICE DERDERIAN LICENSED CLINICAL SOCIAL WORKER INC
Entity Type:Organization
Organization Name:JANICE DERDERIAN LICENSED CLINICAL SOCIAL WORKER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:DERDERIAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:562-795-6300
Mailing Address - Street 1:PO BOX 2685
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-1685
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1661 GOLDEN RAIN RD
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-4907
Practice Address - Country:US
Practice Address - Phone:562-795-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASW73881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W18558Medicare PIN