=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306941729
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONNAMARIE DZIKOWSKI LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 07/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 221 BROADWAY SUITE 202B
-----------------------------------------------------
City | AMITYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11701-2780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-574-4606
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 280 WALNUT ST
-----------------------------------------------------
City | LINDENHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11757-4732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-769-8453
-----------------------------------------------------
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 | R045761-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------