MEDICARE: DGMANDEL A LICENSED CLINICAL SOCIAL WORKER CORPORATION

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

General Provider Information

NPI Number	:	1740881176
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DGMANDEL A LICENSED CLINICAL SOCIAL WORKER CORPORATION

Provider Business Mailing Address
First Line	:	137 N LARCHMONT BLVD # 476
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-3704
Country	:	US
Telephone Number	:	323-325-5346
Fax Number	:

Provider Business Practice Location Address
First Line	:	5757 WILSHIRE BLVD STE 439
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-3628
Country	:	US
Telephone Number	:	310-579-9355
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DENICA GORDON MANDEL
Credential	:	M.A., MSW, LCSW
Telephone Number	:	323-325-5346

Provider Enumeration Date	:	11/03/2020
Last Update Date	:	11/03/2020

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