Provider Demographics
NPI:1598479982
Name:TRUE LIVING THERAPY LICENSED CLINICAL SOCIAL WORKER, INC
Entity type:Organization
Organization Name:TRUE LIVING THERAPY LICENSED CLINICAL SOCIAL WORKER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TOMIKKA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:559-999-9871
Mailing Address - Street 1:9106 CAMBRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-8595
Mailing Address - Country:US
Mailing Address - Phone:559-999-9871
Mailing Address - Fax:707-981-4350
Practice Address - Street 1:1 HARBOR CTR STE 240
Practice Address - Street 2:
Practice Address - City:SUISUN CITY
Practice Address - State:CA
Practice Address - Zip Code:94585-2449
Practice Address - Country:US
Practice Address - Phone:707-410-0377
Practice Address - Fax:707-981-4350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA61843OtherSTATE LICENSE