=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154644292
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUTHERAN MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2010
-----------------------------------------------------
Last Update Date | 03/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 55TH ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11220-2559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-230-5707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 55TH ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11220-2559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER
-----------------------------------------------------
Name | MICHELLE FELDER
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 718-230-5707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number | 073857-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------