=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922699610
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIGO DOVE LCSW THERAPY WELLNESS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2021
-----------------------------------------------------
Last Update Date | 07/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 ATLANTIC AVE
-----------------------------------------------------
City | BALDWIN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11510-4247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-220-2244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2829 ALDER RD
-----------------------------------------------------
City | BELLMORE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11710-4700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RENAE TRAMONTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-220-2244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------