Provider Demographics
NPI:1285633776
Name:NESSELLE, SHARON (MFT)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:NESSELLE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1168
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90078-1168
Mailing Address - Country:US
Mailing Address - Phone:323-993-7500
Mailing Address - Fax:323-308-4015
Practice Address - Street 1:1625 SCHRADER BLVD
Practice Address - Street 2:4TH FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-6213
Practice Address - Country:US
Practice Address - Phone:323-993-7500
Practice Address - Fax:323-308-4015
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC34130106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC34130OtherSTATE LICENSE #
CAMFC34130Medicare ID - Type UnspecifiedMEDICARE ID #