MEDICARE: LISA IGLESIAS-MAERZ 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	R048491-1	NY

General Provider Information

NPI Number	:	1053709899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA IGLESIAS-MAERZ LCSW

Provider Business Mailing Address
First Line	:	75 PROSPECT ST STE 208
Second Line	:
City	:	HUNTINGTON
State	:	NY
Zip	:	11743-3310
Country	:	US
Telephone Number	:	631-807-7102
Fax Number	:	631-427-0388

Provider Business Practice Location Address
First Line	:	75 PROSPECT ST STE 208
Second Line	:
City	:	HUNTINGTON
State	:	NY
Zip	:	11743-3310
Country	:	US
Telephone Number	:	631-807-7102
Fax Number	:	631-427-0388

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

Provider Enumeration Date	:	01/01/2015
Last Update Date	:	01/29/2018

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