MEDICARE: KIMBERLY G LASCANO MFT

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	106H00000X	Marriage & Family Therapist	MFC23364	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	954209286	OTHER	CA	TAX ID

General Provider Information

NPI Number	:	1114090172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY G LASCANO MFT

Provider Business Mailing Address
First Line	:	4368 EAGLE ROCK BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-3211
Country	:	US
Telephone Number	:	323-256-9906
Fax Number	:	323-256-9916

Provider Business Practice Location Address
First Line	:	4368 EAGLE ROCK BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-3211
Country	:	US
Telephone Number	:	323-256-9906
Fax Number	:	323-256-9916

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

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	07/08/2007

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