MEDICARE: MS. MICHELLE GENEVIEVE DE LOS SANTOS 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	LCS18256	CA

General Provider Information

NPI Number	:	1366164527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MICHELLE GENEVIEVE DE LOS SANTOS MSW, LCSW

Provider Business Mailing Address
First Line	:	1953 HOMEWOOD DR
Second Line	:
City	:	ALTADENA
State	:	CA
Zip	:	91001-2839
Country	:	US
Telephone Number	:	626-922-0599
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 N ROOSEVELT AVE
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-3621
Country	:	US
Telephone Number	:	626-922-0599
Fax Number	:

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

Provider Enumeration Date	:	09/14/2022
Last Update Date	:	09/14/2022

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