=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740262310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. AVIVA ZIGELMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 445 NORTHERN BLVD STE 12
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-4804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-625-1617
-----------------------------------------------------
Fax | 718-423-9705
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 445 NORTHERN BLVD STE 12
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-4804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-625-1617
-----------------------------------------------------
Fax | 718-423-9705
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | R0191571
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------