MEDICARE: TAMARA DE ANGELIS LICENSED CLINICAL SOCIAL WORKER, INC.

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

General Provider Information

NPI Number	:	1164199618
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAMARA DE ANGELIS LICENSED CLINICAL SOCIAL WORKER, INC.

Provider Business Mailing Address
First Line	:	2272 COLORADO BLVD STE 1164
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-1143
Country	:	US
Telephone Number	:	323-925-5279
Fax Number	:

Provider Business Practice Location Address
First Line	:	2272 COLORADO BLVD STE 1164
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-1143
Country	:	US
Telephone Number	:	323-925-5279
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TAMARA DEANGELIS
Credential	:	LCSW
Telephone Number	:	609-338-2244

Provider Enumeration Date	:	08/24/2021
Last Update Date	:	08/24/2021

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