=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659523926
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARTIN JAY GOLLOUB LCSW, BCD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2008
-----------------------------------------------------
Last Update Date | 10/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 66 SUGAR MAPLE LN
-----------------------------------------------------
City | GLEN COVE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11542-1632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-676-3830
-----------------------------------------------------
Fax | 516-759-9503
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 66 SUGAR MAPLE LN
-----------------------------------------------------
City | GLEN COVE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11542-1632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-676-3830
-----------------------------------------------------
Fax | 516-759-9503
-----------------------------------------------------
=====================================================
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 | PR014204-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------