MEDICARE: INTEGRAL ENRICHMENT SERVICES

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

General Provider Information

NPI Number	:	1043469380
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRAL ENRICHMENT SERVICES

Provider Business Mailing Address
First Line	:	72 GUY LOMBARDO AVE
Second Line	:	SUITE # 2
City	:	FREEPORT
State	:	NY
Zip	:	11520-3742
Country	:	US
Telephone Number	:	516-623-2162
Fax Number	:	631-888-0431

Provider Business Practice Location Address
First Line	:	72 GUY LOMBARDO AVE
Second Line	:	SUITE # 2
City	:	FREEPORT
State	:	NY
Zip	:	11520-3742
Country	:	US
Telephone Number	:	516-623-2162
Fax Number	:	631-888-0431

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. PRISKA IMBERTI
Credential	:	LCSW
Telephone Number	:	516-623-2162

Provider Enumeration Date	:	09/11/2008
Last Update Date	:	09/11/2008

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