MEDICARE: SHARON NESSELLE M.F.T.

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	MFC34130	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MFC34130	OTHER	CA	STATE LICENSE #

General Provider Information

NPI Number	:	1285633776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHARON NESSELLE M.F.T.

Provider Business Mailing Address
First Line	:	PO BOX 1168
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90078-1168
Country	:	US
Telephone Number	:	323-993-7500
Fax Number	:	323-308-4015

Provider Business Practice Location Address
First Line	:	1625 SCHRADER BLVD
Second Line	:	4TH FLOOR
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-6213
Country	:	US
Telephone Number	:	323-993-7500
Fax Number	:	323-308-4015

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

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	07/08/2007

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