MEDICARE: MARK FAIRFIELD 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	LCS19969	CA

General Provider Information

NPI Number	:	1861924045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK FAIRFIELD LCSW

Provider Business Mailing Address
First Line	:	2717 S ROBERTSON BLVD
Second Line	:	SUITE D
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-2442
Country	:	US
Telephone Number	:	310-339-0609
Fax Number	:

Provider Business Practice Location Address
First Line	:	2717 S ROBERTSON BLVD
Second Line	:	SUITE D
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-2442
Country	:	US
Telephone Number	:	310-339-0609
Fax Number	:

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

Provider Enumeration Date	:	03/28/2017
Last Update Date	:	03/28/2017

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