Healthcare Provider Details

I. General information

NPI: 1962788570
Provider Name (Legal Business Name): ANNALISE KORDELL L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2011
Last Update Date: 12/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 E MOUNTAIN ST
PASADENA CA
91104-4606
US

IV. Provider business mailing address

1065 E MOUNTAIN ST
PASADENA CA
91104-4606
US

V. Phone/Fax

Practice location:
  • Phone: 626-240-9193
  • Fax:
Mailing address:
  • Phone: 626-240-9193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 28268
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.012882
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: