MEDICARE: MR. SCOTT MASTERS WALLACH 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	LCS15623	CA

General Provider Information

NPI Number	:	1780769273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SCOTT MASTERS WALLACH LCSW

Provider Business Mailing Address
First Line	:	921 E. COMPTON BLVD., FIRST FLOOR
Second Line	:
City	:	COMPTON
State	:	CA
Zip	:	90221-3303
Country	:	US
Telephone Number	:	310-668-6860
Fax Number	:

Provider Business Practice Location Address
First Line	:	921 E. COMPTON BLVD., FIRST FLOOR
Second Line	:
City	:	COMPTON
State	:	CA
Zip	:	90221-3303
Country	:	US
Telephone Number	:	310-668-6860
Fax Number	:

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

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	09/29/2008

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