=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184895047
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENISE S. MATSUMOTO LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2008
-----------------------------------------------------
Last Update Date | 05/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4060 WATSON PLAZA DRIVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-650-6178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2889 PLAZA DEL AMO UNIT 123
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90503-7377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-650-6178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCS 16406
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------