=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235457169
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELVIN J CHAN LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2010
-----------------------------------------------------
Last Update Date | 05/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 JORALEMON ST 3RD FLOOR
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11201-3743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-250-5557
-----------------------------------------------------
Fax | 718-250-4757
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 THISTLE LN
-----------------------------------------------------
City | WILTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06897-4125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-246-6497
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 080210
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------