MEDICARE: JERYL DINA SKINNER 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	070279	NY

General Provider Information

NPI Number	:	1215166608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERYL DINA SKINNER LCSW

Provider Business Mailing Address
First Line	:	349 BEACH 57TH ST
Second Line	:	APT 6D
City	:	ARVERNE
State	:	NY
Zip	:	11692-1646
Country	:	US
Telephone Number	:	718-318-0467
Fax Number	:

Provider Business Practice Location Address
First Line	:	349 BEACH 57TH ST
Second Line	:	APT 6D
City	:	ARVERNE
State	:	NY
Zip	:	11692-1646
Country	:	US
Telephone Number	:	718-318-0467
Fax Number	:

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

Provider Enumeration Date	:	07/07/2009
Last Update Date	:	07/07/2009

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