MEDICARE: MS. ANNUNZIATA JOHANNA PAULINA VAN VOORENE 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	101YP2500X	Professional Counselor	LCSW78653	CA

General Provider Information

NPI Number	:	1083131791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANNUNZIATA JOHANNA PAULINA VAN VOORENE LCSW

Provider Business Mailing Address
First Line	:	P.O. BOX 1127
Second Line	:
City	:	LOWER LAKE
State	:	CA
Zip	:	95457
Country	:	US
Telephone Number	:	707-480-7319
Fax Number	:

Provider Business Practice Location Address
First Line	:	11686 SPRUCE GROVE RD
Second Line	:
City	:	LOWER LAKE
State	:	CA
Zip	:	95457-9545
Country	:	US
Telephone Number	:	707-994-4053
Fax Number	:

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

Provider Enumeration Date	:	08/23/2017
Last Update Date	:	08/23/2017

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