Provider Demographics
NPI:1063871291
Name:TARDANICO, PHILLIP GEORGE (LCSW 69611)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:GEORGE
Last Name:TARDANICO
Suffix:
Gender:M
Credentials:LCSW 69611
Other - Prefix:MR
Other - First Name:PHILLIP
Other - Middle Name:
Other - Last Name:TARDANICO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW, MAC, & SAP
Mailing Address - Street 1:15000 SEVENTH ST STE 209
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-3853
Mailing Address - Country:US
Mailing Address - Phone:760-217-9527
Mailing Address - Fax:442-267-5623
Practice Address - Street 1:15000 SEVENTH ST STE 209
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3853
Practice Address - Country:US
Practice Address - Phone:760-217-9527
Practice Address - Fax:442-267-5623
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW696111041C0700X
CAA01210315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA800682649Medicaid