=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023171865
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOAN H AZIZOLLAHOFF LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 E 42 ST SUITE 507
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-872-0577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14430 35 AVE APT B64
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-353-7783
-----------------------------------------------------
Fax | 718-659-1405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R0428471
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------