MEDICARE: MARK FAIRFIELD, LCSW, BCD, A LICENSED CLINICAL SOCIAL WORK CORPORATION

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	251S00000X	Community/Behavioral Health Agency	LCS19969	CA

General Provider Information

NPI Number	:	1174762058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK FAIRFIELD, LCSW, BCD, A LICENSED CLINICAL SOCIAL WORK CORPORATION

Provider Business Mailing Address
First Line	:	612 N SEPULVEDA BLVD
Second Line	:	STE. 3
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-2175
Country	:	US
Telephone Number	:	310-339-0609
Fax Number	:	877-768-2272

Provider Business Practice Location Address
First Line	:	612 N SEPULVEDA BLVD
Second Line	:	STE. 3
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-2175
Country	:	US
Telephone Number	:	310-339-0609
Fax Number	:	877-768-2272

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MARK FAIRFIELD
Credential	:	LCSW
Telephone Number	:	310-339-0609

Provider Enumeration Date	:	02/17/2009
Last Update Date	:	02/17/2009

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