MEDICARE: MRS. LAURIE EDDLESTON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	25413	CA

General Provider Information

NPI Number	:	1073211181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURIE EDDLESTON LCSW

Provider Business Mailing Address
First Line	:	2629 MANHATTAN AVE
Second Line	:
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-2411
Country	:	US
Telephone Number	:	310-739-3844
Fax Number	:

Provider Business Practice Location Address
First Line	:	421 7TH ST
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-5615
Country	:	US
Telephone Number	:	310-739-3844
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/17/2023
Last Update Date	:	02/17/2023

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