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General NPI Number Information
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NPI Number | 1174762058
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Entity Type | Organization
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Legal Business Name | MARK FAIRFIELD, LCSW, BCD, A LICENSED CLINICAL SOCIAL WORK CORPORATION
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Dates
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Enumeration Date | 02/17/2009
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Last Update Date | 02/17/2009
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Provider Practice Location Address
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Address Line | 612 N SEPULVEDA BLVD STE. 3
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City | LOS ANGELES
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State | CA
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Zip | 90049-2175
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Country | US
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Telephone | 310-339-0609
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Fax | 877-768-2272
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Provider Business Mailing Address
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Address Line | 612 N SEPULVEDA BLVD STE. 3
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City | LOS ANGELES
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State | CA
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Zip | 90049-2175
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Country | US
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Telephone | 310-339-0609
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Fax | 877-768-2272
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | MARK FAIRFIELD
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Credential | LCSW
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Telephone | 310-339-0609
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LCS19969
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License Number State | CA
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