Healthcare Provider Details

I. General information

NPI: 1043359268
Provider Name (Legal Business Name): ELAINE FIDEL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S BEVERLY DR SUITE 103
BEVERLY HILLS CA
90212-4424
US

IV. Provider business mailing address

400 S BEVERLY DR SUITE 103
BEVERLY HILLS CA
90212-4424
US

V. Phone/Fax

Practice location:
  • Phone: 310-553-5848
  • Fax: 310-553-5848
Mailing address:
  • Phone: 310-553-5848
  • Fax: 310-553-5848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLY008249
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: