=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437474590
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANASTASIA CHOMANCZUK LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2010
-----------------------------------------------------
Last Update Date | 04/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3811 BROADWAY
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11103-4045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-726-5953
-----------------------------------------------------
Fax | 718-204-5308
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3811 BROADWAY
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11103-4045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-726-5953
-----------------------------------------------------
Fax | 718-204-5308
-----------------------------------------------------
=====================================================
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 | 073273
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------