=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669561635
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES GRECO LCSW-R,BCD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 37 RANDALL RD PO 32
-----------------------------------------------------
City | WADING RIVER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-929-1400
-----------------------------------------------------
Fax | 631-929-1400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 JOANN COURT P.O. 827
-----------------------------------------------------
City | EASTPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-929-1400
-----------------------------------------------------
Fax | 631-929-1400
-----------------------------------------------------
=====================================================
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 | PR022710
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------