Provider Demographics
NPI:1396874822
Name:ODERBERG, ETHEL SUSAN (MSW)
Entity type:Individual
Prefix:MRS
First Name:ETHEL
Middle Name:SUSAN
Last Name:ODERBERG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3313 BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-1305
Mailing Address - Country:US
Mailing Address - Phone:310-391-0076
Mailing Address - Fax:310-391-0076
Practice Address - Street 1:10516 SANTA MONICA BLVD
Practice Address - Street 2:#3
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4964
Practice Address - Country:US
Practice Address - Phone:310-391-0076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA124171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical