MEDICARE: LENA ADDO, INCORPORATED

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	103TC0700X	Clinical Psychologist	013403	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609058809
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LENA ADDO, INCORPORATED

Provider Business Mailing Address
First Line	:	621 GATES AVEUNE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11221-1243
Country	:	US
Telephone Number	:	917-755-6976
Fax Number	:

Provider Business Practice Location Address
First Line	:	621 GATES AVENUE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11221-1243
Country	:	US
Telephone Number	:	917-755-6976
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	LENA ADDO
Credential	:	PH.D
Telephone Number	:	917-755-6976

Provider Enumeration Date	:	11/29/2007
Last Update Date	:	11/29/2007

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