MEDICARE: RISA SHERWOOD GORDON MFT

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	106H00000X	Marriage & Family Therapist	15299	CA

General Provider Information

NPI Number	:	1104029891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RISA SHERWOOD GORDON MFT

Provider Business Mailing Address
First Line	:	3641 TILDEN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-6909
Country	:	US
Telephone Number	:	310-837-6368
Fax Number	:	310-837-3486

Provider Business Practice Location Address
First Line	:	3760 MOTOR AVE
Second Line	:	SUITE 311
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-6404
Country	:	US
Telephone Number	:	310-837-6368
Fax Number	:	310-837-3486

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

Provider Enumeration Date	:	06/08/2007
Last Update Date	:	07/08/2007

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