=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518311869
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BARBARA MCKENNA FOLKS LCSW-R
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2016
-----------------------------------------------------
Last Update Date | 04/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1717 N OCEAN AVE
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11763-2678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-949-6009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 57 EVERGREEN LN
-----------------------------------------------------
City | EAST PATCHOGUE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11772-5803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-949-6009
-----------------------------------------------------
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 | R070377-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------