Basic Information
| Provider Information | |||||||||
| NPI: | 1285633776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NESSELLE | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.F.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1168 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900781168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3239937500 | ||||||||
| FaxNumber: | 3233084015 | ||||||||
| Practice Location | |||||||||
| Address1: | 1625 SCHRADER BLVD | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900286213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3239937500 | ||||||||
| FaxNumber: | 3233084015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC34130 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | MFC34130 | 01 | CA | STATE LICENSE # | OTHER |