=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750508354
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENA PRYBUTOK L.C.S.W.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 UNION SQ E SUITE 805
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-3209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-221-7873
-----------------------------------------------------
Fax | 516-759-9883
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 E 56TH ST APT. 6D
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10022-3623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-221-7873
-----------------------------------------------------
Fax | 516-759-9883
-----------------------------------------------------
=====================================================
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 | R0692281-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------