=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972673754
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. CAROL A DANDREA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25504 58 AVENUE
-----------------------------------------------------
City | LITTLE NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11362-2149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-224-2253
-----------------------------------------------------
Fax | 718-224-2253
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25504 58 AVENUE
-----------------------------------------------------
City | LITTLE NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11362-2149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-224-2253
-----------------------------------------------------
Fax | 718-224-2253
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | R0419771
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------