=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669874327
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DORE MANN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2014
-----------------------------------------------------
Last Update Date | 09/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4747 46TH ST APT 1F
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-6544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-843-3692
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47-47 46 STREET APARTMENT 1F
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 089817
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------