Provider Demographics
NPI:1114694338
Name:USTINOVA, KSENIA (ACSW)
Entity type:Individual
Prefix:
First Name:KSENIA
Middle Name:
Last Name:USTINOVA
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9683
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96158-2683
Mailing Address - Country:US
Mailing Address - Phone:916-248-9264
Mailing Address - Fax:
Practice Address - Street 1:2100 ELOISE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-4306
Practice Address - Country:US
Practice Address - Phone:530-544-1748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA118870104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker