MEDICARE: SILVANA POLA DE JONGHE 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	11544	CA

General Provider Information

NPI Number	:	1700040409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SILVANA POLA DE JONGHE LCSW

Provider Business Mailing Address
First Line	:	705 4TH ST
Second Line	:	SUITE 200
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-3233
Country	:	US
Telephone Number	:	707-824-9032
Fax Number	:

Provider Business Practice Location Address
First Line	:	705 4TH ST
Second Line	:	SUITE 200
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-3233
Country	:	US
Telephone Number	:	707-824-9032
Fax Number	:

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

Provider Enumeration Date	:	07/11/2008
Last Update Date	:	07/18/2008

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