MEDICARE: LASSANA DEMBELE

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	BH002542	PA

General Provider Information

NPI Number	:	1841697620
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LASSANA DEMBELE

Provider Business Mailing Address
First Line	:	237 SANSOM ST APT A
Second Line	:
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-3111
Country	:	US
Telephone Number	:	267-678-9113
Fax Number	:

Provider Business Practice Location Address
First Line	:	237 SANSOM ST APT A
Second Line	:
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-3111
Country	:	US
Telephone Number	:	267-678-9113
Fax Number	:

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

Provider Enumeration Date	:	11/23/2014
Last Update Date	:	11/23/2014

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Directions to “ LASSANA DEMBELE ” Practice Location

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