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General NPI Number Information
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NPI Number | 1942352034
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Entity Type | Individual
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Provider Name | LARISSA ELLEN GOLLOUB LCSW-R
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Gender | Female
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Dates
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Enumeration Date | 01/17/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2581 ATLANTIC AVE 2ND FLOOR
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City | BROOKLYN
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State | NY
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Zip | 11207-2412
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Country | US
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Telephone | 718-890-8100
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Fax | 718-495-8298
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Provider Business Mailing Address
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Address Line | 11115 75TH AVE APT. 5M
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City | FOREST HILLS
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State | NY
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Zip | 11375-6327
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Country | US
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Telephone | 718-890-8100
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Fax | 718-495-8298
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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 | R050308-1
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License Number State | NY
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