MEDICARE: RENEE M ROYCESTON LMSW

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	086095	NY

General Provider Information

NPI Number	:	1033474689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENEE M ROYCESTON LMSW

Provider Business Mailing Address
First Line	:	2215 43RD AVE
Second Line	:	2ND FLOOR
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-5018
Country	:	US
Telephone Number	:	718-389-5100
Fax Number	:	718-752-4809

Provider Business Practice Location Address
First Line	:	522 COURTLANDT AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10451-5008
Country	:	US
Telephone Number	:	718-585-2153
Fax Number	:

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

Provider Enumeration Date	:	07/10/2012
Last Update Date	:	07/10/2012

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