MEDICARE: MISS KRISTIN ASHLEY FAUTH B.A.

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1770607855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KRISTIN ASHLEY FAUTH B.A.

Provider Business Mailing Address
First Line	:	1300 S CATALINA AVE
Second Line	:	APT 215
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5021
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	21707 HAWTHORNE BLVD
Second Line	:	STE 300
City	:	TORRANCE
State	:	CA
Zip	:	90503-7009
Country	:	US
Telephone Number	:	310-543-9900
Fax Number	:	310-543-9910

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

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	07/08/2007

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