MEDICARE: MRS. MARCIA BLANK 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	104100000X	Social Worker	R13959	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7493669	OTHER	NY	EMPIRE

General Provider Information

NPI Number	:	1154461879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARCIA BLANK LCSW

Provider Business Mailing Address
First Line	:	46 BARBERRY LN
Second Line	:
City	:	ROSLYN HEIGHTS
State	:	NY
Zip	:	11577-1502
Country	:	US
Telephone Number	:	516-621-4278
Fax Number	:	516-621-4275

Provider Business Practice Location Address
First Line	:	46 BARBERRY LN
Second Line	:
City	:	ROSLYN HEIGHTS
State	:	NY
Zip	:	11577-1502
Country	:	US
Telephone Number	:	516-621-4278
Fax Number	:	516-621-4275

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

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	07/08/2007

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