MEDICARE: GINA ANN POLESE-GROSSO 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	44SC00199100	NJ

General Provider Information

NPI Number	:	1487082921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA ANN POLESE-GROSSO LCSW

Provider Business Mailing Address
First Line	:	123 BRISCOE DR
Second Line	:
City	:	TOMS RIVER
State	:	NJ
Zip	:	08753-3140
Country	:	US
Telephone Number	:	732-458-1700
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 ROUTE 88
Second Line	:
City	:	BRICK
State	:	NJ
Zip	:	08724-2320
Country	:	US
Telephone Number	:	732-458-1700
Fax Number	:

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

Provider Enumeration Date	:	10/18/2013
Last Update Date	:	10/18/2013

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