MEDICARE: ELLEN ROESE 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	LCS28673	CA
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1730438714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN ROESE LCSW

Provider Business Mailing Address
First Line	:	326 S PCH HWY
Second Line	:	SUITE 206
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-3737
Country	:	US
Telephone Number	:	310-567-5975
Fax Number	:

Provider Business Practice Location Address
First Line	:	326 S PCH HWY
Second Line	:	SUITE 206
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-3737
Country	:	US
Telephone Number	:	310-567-5975
Fax Number	:

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

Provider Enumeration Date	:	09/05/2012
Last Update Date	:	09/05/2012

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Directions to “ ELLEN ROESE LCSW” Practice Location

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