=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871611202
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA TEYTEL LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3722 82ND ST
-----------------------------------------------------
City | JACKSON HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11372-7032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-779-1600
-----------------------------------------------------
Fax | 718-803-0895
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7410 35TH AVE 215W
-----------------------------------------------------
City | JACKSON HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11372-8160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-672-1017
-----------------------------------------------------
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 | 0717841
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------