MEDICARE: VANESSA ANNE NISPEROS LMSW

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	103063	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	103063	OTHER	NY	NEW YORK STATE OFFICE OF THE PROFESSIONS

General Provider Information

NPI Number	:	1235743378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANESSA ANNE NISPEROS LMSW

Provider Business Mailing Address
First Line	:	560 RUGBY RD APT 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-1502
Country	:	US
Telephone Number	:	917-620-8197
Fax Number	:

Provider Business Practice Location Address
First Line	:	108 KENILWORTH PL
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-2439
Country	:	US
Telephone Number	:	347-627-8400
Fax Number	:

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

Provider Enumeration Date	:	09/05/2020
Last Update Date	:	09/05/2020

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