MEDICARE: MR. JAN-KEES GEORGE VAN DER GAAG MSW, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS23674	CA
2	1041C0700X	Clinical Social Worker	LCSW23674	CA

General Provider Information

NPI Number	:	1093970378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAN-KEES GEORGE VAN DER GAAG MSW, LCSW

Provider Business Mailing Address
First Line	:	2630 HOLLYRIDGE DRIVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90068
Country	:	US
Telephone Number	:	323-487-1784
Fax Number	:	310-423-7169

Provider Business Practice Location Address
First Line	:	2630 HOLLYRIDGE DRIVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90068
Country	:	US
Telephone Number	:	323-487-1784
Fax Number	:	310-423-7169

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2008
Last Update Date	:	07/05/2022

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Directions to “ MR. JAN-KEES GEORGE VAN DER GAAG MSW, LCSW” Practice Location

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