=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801306782
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY RUFFOLO QUINN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2017
-----------------------------------------------------
Last Update Date | 10/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 W GRAND AVE STE 9
-----------------------------------------------------
City | EL SEGUNDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90245-5111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-816-9166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 935 MAIN ST APT 106
-----------------------------------------------------
City | EL SEGUNDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90245-5210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 76683
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------