=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760410872
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERARD A POLITO I LCSW-R
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1641 DEER PARK AVE SUITE C
-----------------------------------------------------
City | DEER PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-447-5389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 GLEN HOLLOW DR. APT. B7
-----------------------------------------------------
City | HOLTSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-447-5389
-----------------------------------------------------
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 | R028830-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------