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General NPI Number Information
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NPI Number | 1881096410
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Entity Type | Individual
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Provider Name | DONNELL EUGENE WILLCOT JR. M.S.W., A.S.W
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Gender | Male
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Dates
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Enumeration Date | 09/26/2014
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Last Update Date | 09/26/2014
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Provider Practice Location Address
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Address Line | 1801 LAKE SHORE AVE
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City | LOS ANGELES
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State | CA
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Zip | 90026-1715
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Country | US
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Telephone | 323-580-0643
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Fax |
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Provider Business Mailing Address
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Address Line | 13616 CERISE AVE APT. 5
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City | HAWTHORNE
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State | CA
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Zip | 90250-7791
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Country | US
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Telephone | 310-691-9174
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 61466
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License Number State | CA
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