Provider Demographics
NPI:1215259130
Name:MIRISCH, ROBERTA E (LCSW)
Entity type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:E
Last Name:MIRISCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16311 VENTURA BLVD STE 1120
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4356
Mailing Address - Country:US
Mailing Address - Phone:818-783-4140
Mailing Address - Fax:
Practice Address - Street 1:16311 VENTURA BLVD STE 1120
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4356
Practice Address - Country:US
Practice Address - Phone:818-783-4140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-19
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 166151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-4436501OtherBLUE CROSS OF CALIFORNIA