=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396235214
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID EVAN PEZENIK LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2018
-----------------------------------------------------
Last Update Date | 05/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 W 70TH ST APT 16R
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10023-4329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-678-9106
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 W 70TH ST APT 16R
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10023-4329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-678-9106
-----------------------------------------------------
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 | R045-1841
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------