MEDICARE: DONNA M DAPOLITO LCSWR

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	R071035	NY

General Provider Information

NPI Number	:	1255697538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA M DAPOLITO LCSWR

Provider Business Mailing Address
First Line	:	90 WESTERN AVENUE
Second Line	:
City	:	AMSTERDAM
State	:	NY
Zip	:	12010-8464
Country	:	US
Telephone Number	:	518-882-7120
Fax Number	:

Provider Business Practice Location Address
First Line	:	1153 BURGOYNE AVENUE, SUITE 2
Second Line	:
City	:	FORT EDWARD
State	:	NY
Zip	:	12828-1134
Country	:	US
Telephone Number	:	518-746-3340
Fax Number	:

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

Provider Enumeration Date	:	04/11/2012
Last Update Date	:	04/11/2012

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