MEDICARE: SUSAN ELIZABETH GENTILUCCI 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	1041C0700X	Clinical Social Worker	LCSW5621	CA

General Provider Information

NPI Number	:	1316909971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN ELIZABETH GENTILUCCI LCSW

Provider Business Mailing Address
First Line	:	1560 E CHEVY CHASE DRIVE
Second Line	:	SUITE 130
City	:	GLENDALE
State	:	CA
Zip	:	91206-4140
Country	:	US
Telephone Number	:	818-240-0340
Fax Number	:	818-545-7672

Provider Business Practice Location Address
First Line	:	1560 E CHEVY CHASE DRIVE
Second Line	:	SUITE 130
City	:	GLENDALE
State	:	CA
Zip	:	91206-4140
Country	:	US
Telephone Number	:	818-240-0340
Fax Number	:	818-545-7672

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

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	07/08/2007

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