MEDICARE: MS. ITA ILLENE GOLUS

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	078776-1	NY

General Provider Information

NPI Number	:	1801961651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ITA ILLENE GOLUS

Provider Business Mailing Address
First Line	:	1632 E 32ND ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-4213
Country	:	US
Telephone Number	:	917-971-9594
Fax Number	:

Provider Business Practice Location Address
First Line	:	1632 E 32ND ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-4213
Country	:	US
Telephone Number	:	917-971-9594
Fax Number	:

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

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	06/04/2013

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