=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033472196
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOVE CHILD, LCSW P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2012
-----------------------------------------------------
Last Update Date | 06/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3309 AVENUE J
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11210-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-251-4891
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3309 AVENUE J
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11210-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER
-----------------------------------------------------
Name | MELISSA HILLARY GRAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-251-4891
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | P051882-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------