Provider Demographics
NPI:1952966053
Name:SHAUNEET MARDUK, LICENSE CLINICAL SOCIAL WORKER INC.
Entity type:Organization
Organization Name:SHAUNEET MARDUK, LICENSE CLINICAL SOCIAL WORKER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:SHAUNEET
Authorized Official - Middle Name:EVE
Authorized Official - Last Name:MARDUK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:818-489-7137
Mailing Address - Street 1:PO BOX 5200
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91413-5200
Mailing Address - Country:US
Mailing Address - Phone:818-489-7137
Mailing Address - Fax:818-475-1646
Practice Address - Street 1:25101 THE OLD RD STE 131
Practice Address - Street 2:
Practice Address - City:STEVENSON RANCH
Practice Address - State:CA
Practice Address - Zip Code:91381-2206
Practice Address - Country:US
Practice Address - Phone:818-489-7137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-03
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty