MEDICARE: SHOSHANA M BULOW LCSW, PHD

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	R056721	NY

General Provider Information

NPI Number	:	1336474261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHOSHANA M BULOW LCSW, PHD

Provider Business Mailing Address
First Line	:	4520 WALDO AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10471-3942
Country	:	US
Telephone Number	:	212-696-8679
Fax Number	:

Provider Business Practice Location Address
First Line	:	4520 WALDO AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10471-3942
Country	:	US
Telephone Number	:	212-696-8679
Fax Number	:

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

Provider Enumeration Date	:	10/09/2009
Last Update Date	:	11/25/2022

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