=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811017262
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL NALIETH LCSW-R, PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 N PORTLAND AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11205-2005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-260-4814
-----------------------------------------------------
Fax | 718-260-7711
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 RIDGEVIEW AVE
-----------------------------------------------------
City | WEST ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07052-4315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-262-4556
-----------------------------------------------------
Fax | 973-731-5808
-----------------------------------------------------
=====================================================
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 | R051289-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------