MEDICARE: MS. ELISE DEMERDJIAN 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	LCS12246	CA

General Provider Information

NPI Number	:	1245395912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELISE DEMERDJIAN LCSW

Provider Business Mailing Address
First Line	:	1146 N CENTRAL AVE # 134
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91202-2506
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1146 N CENTRAL AVE # 134
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91202-2506
Country	:	US
Telephone Number	:	818-500-0511
Fax Number	:

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

Provider Enumeration Date	:	12/23/2006
Last Update Date	:	03/09/2012

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