=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073915393
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANA ROSEL MASSARO LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2014
-----------------------------------------------------
Last Update Date | 09/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33 N TYSON AVE
-----------------------------------------------------
City | FLORAL PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11001-1514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-623-9296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 N TYSON AVE
-----------------------------------------------------
City | FLORAL PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11001-1514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-623-9296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 081981-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------