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General NPI Number Information
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NPI Number | 1750823506
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Entity Type | Individual
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Provider Name | JOHN TAVOLACCI LCSW
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Gender | Male
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Dates
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Enumeration Date | 11/10/2016
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Last Update Date | 11/10/2016
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Provider Practice Location Address
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Address Line | 120 WALL ST 17TH FLOOR
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City | NEW YORK
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State | NY
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Zip | 10005-3904
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Country | US
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Telephone | 212-361-1622
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Fax | 212-361-3761
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Provider Business Mailing Address
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Address Line | 207 HOWARD ST
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City | EAST WILLISTON
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State | NY
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Zip | 11596-1421
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Country | US
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Telephone | 917-584-7068
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Fax | 212-361-3761
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 069437-1
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License Number State | NY
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