MEDICARE: HANNAH ELISE BALES 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	60692	CA

General Provider Information

NPI Number	:	1356414734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HANNAH ELISE BALES LCSW

Provider Business Mailing Address
First Line	:	5224 ETRUSCAN DR
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94534-4086
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2460 CLAY BANK RD
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-1655
Country	:	US
Telephone Number	:	707-399-4894
Fax Number	:

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

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	10/25/2022

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