Provider Demographics
NPI:1386983393
Name:INNIS-THOMPSON, MIRTA ELVIRE (LCSW)
Entity type:Individual
Prefix:
First Name:MIRTA
Middle Name:ELVIRE
Last Name:INNIS-THOMPSON
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 1:12529 GREY FOX LN
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-1903
Mailing Address - Country:US
Mailing Address - Phone:619-869-0771
Mailing Address - Fax:
Practice Address - Street 1:10880 WILSHIRE BLVD STE 1101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4112
Practice Address - Country:US
Practice Address - Phone:619-869-0771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-11
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1019061041C0700X
CAASW667171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical