MEDICARE: MS. TERRI ANNE COYLE FAMULARO LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R054801-1	NY

General Provider Information

NPI Number	:	1033295498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TERRI ANNE COYLE FAMULARO LCSW

Provider Business Mailing Address
First Line	:	1908 BROOKHAVEN AVE
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-3626
Country	:	US
Telephone Number	:	718-869-8400
Fax Number	:	718-869-8405

Provider Business Practice Location Address
First Line	:	1908 BROOKHAVEN AVE
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-3626
Country	:	US
Telephone Number	:	718-869-8400
Fax Number	:	718-869-8405

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2006
Last Update Date	:	01/05/2018

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