MEDICARE: MS. ANNALISE KORDELL L.C.S.W.

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	LCS 28268	CA
2	1041C0700X	Clinical Social Worker	149.012882	IL

General Provider Information

NPI Number	:	1962788570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANNALISE KORDELL L.C.S.W.

Provider Business Mailing Address
First Line	:	1065 E MOUNTAIN ST
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-4606
Country	:	US
Telephone Number	:	626-240-9193
Fax Number	:

Provider Business Practice Location Address
First Line	:	1065 E MOUNTAIN ST
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-4606
Country	:	US
Telephone Number	:	626-240-9193
Fax Number	:

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

Provider Enumeration Date	:	10/26/2011
Last Update Date	:	12/05/2013

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