MEDICARE: MS. LARISSA ELLEN GOLLOUB LCSW-R

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	R050308-1	NY

General Provider Information

NPI Number	:	1942352034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LARISSA ELLEN GOLLOUB LCSW-R

Provider Business Mailing Address
First Line	:	11115 75TH AVE
Second Line	:	APT. 5M
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-6327
Country	:	US
Telephone Number	:	718-890-8100
Fax Number	:	718-495-8298

Provider Business Practice Location Address
First Line	:	2581 ATLANTIC AVE
Second Line	:	2ND FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11207-2412
Country	:	US
Telephone Number	:	718-890-8100
Fax Number	:	718-495-8298

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

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	07/08/2007

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