=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164638508
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES DENTON WEISS M.S.W.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 NARROWS RD S
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10305-2832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-815-4152
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 MOUNTAIN LAUREL RD
-----------------------------------------------------
City | MORGANVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07751-4066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-617-1492
-----------------------------------------------------
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 | PR014857
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC01378700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------