MEDICARE: MS. ELLEN CATHERINE WAGEMAN 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	071909	NY

General Provider Information

NPI Number	:	1811917446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELLEN CATHERINE WAGEMAN LCSW

Provider Business Mailing Address
First Line	:	7 WESTBURY RD
Second Line	:
City	:	ISELIN
State	:	NJ
Zip	:	08830-2413
Country	:	US
Telephone Number	:	732-750-4744
Fax Number	:

Provider Business Practice Location Address
First Line	:	191 JORALEMON ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11201-4306
Country	:	US
Telephone Number	:	718-722-6062
Fax Number	:	718-722-6217

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

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	07/08/2007

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