MEDICARE: CENTER FOR LEARNING AND GROWTH HEALTH AND WELLNESS SERVICES, LLC

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	225700000X	Massage Therapist	027228	NY
2	101YM0800X	Mental Health Counselor	008172	NY

General Provider Information

NPI Number	:	1972005833
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER FOR LEARNING AND GROWTH HEALTH AND WELLNESS SERVICES, LLC

Provider Business Mailing Address
First Line	:	14101 68TH DR FL 1
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11367-1635
Country	:	US
Telephone Number	:	718-551-1868
Fax Number	:

Provider Business Practice Location Address
First Line	:	14101 68TH DR FL 1
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11367-1635
Country	:	US
Telephone Number	:	718-551-1868
Fax Number	:

Authorized Official
Title or Position	:	COUNSELOR
Name	:	DR. LUIS BRIGNOLO
Credential	:	LMHC
Telephone Number	:	718-551-1868

Provider Enumeration Date	:	03/06/2018
Last Update Date	:	03/06/2018

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14101 68TH DR FL 1
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1831049402 — JEZREEL MOY
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