MEDICARE: ANDREW MICHAEL SUSSKIND 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	LCS 17309	CA

General Provider Information

NPI Number	:	1710037643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW MICHAEL SUSSKIND LCSW

Provider Business Mailing Address
First Line	:	12304 SANTA MONICA BLVD STE 300
Second Line	:
City	:	WEST LOS ANGELES
State	:	CA
Zip	:	90025-2593
Country	:	US
Telephone Number	:	310-281-8681
Fax Number	:	310-450-8114

Provider Business Practice Location Address
First Line	:	12304 SANTA MONICA BLVD STE 300
Second Line	:
City	:	WEST LOS ANGELES
State	:	CA
Zip	:	90025-2593
Country	:	US
Telephone Number	:	310-281-8681
Fax Number	:	310-450-8114

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

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	07/08/2007

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