=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225395627
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDA H RODMAN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2012
-----------------------------------------------------
Last Update Date | 01/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1231 S GRAMERCY PL
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90019-3638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-219-9919
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1231 S GRAMERCY PL
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90019-3638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-219-9919
-----------------------------------------------------
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 17160
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------