MEDICARE: LISA MARIE DAZOLS 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	104100000X	Social Worker

General Provider Information

NPI Number	:	1306900253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARIE DAZOLS LCSW

Provider Business Mailing Address
First Line	:	1390 MARKET ST
Second Line	:	SUITE 800
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94102-5402
Country	:	US
Telephone Number	:	415-255-2165
Fax Number	:	415-255-2101

Provider Business Practice Location Address
First Line	:	1390 MARKET ST
Second Line	:	SUITE 800
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94102-5402
Country	:	US
Telephone Number	:	415-255-2165
Fax Number	:	415-255-2101

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

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	07/08/2007

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