MEDICARE: DONNELL EUGENE WILLCOT JR. M.S.W., A.S.W

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	61466	CA

General Provider Information

NPI Number	:	1881096410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNELL EUGENE WILLCOT JR. M.S.W., A.S.W

Provider Business Mailing Address
First Line	:	13616 CERISE AVE
Second Line	:	APT. 5
City	:	HAWTHORNE
State	:	CA
Zip	:	90250-7791
Country	:	US
Telephone Number	:	310-691-9174
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 LAKE SHORE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90026-1715
Country	:	US
Telephone Number	:	323-580-0643
Fax Number	:

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

Provider Enumeration Date	:	09/26/2014
Last Update Date	:	09/26/2014

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