MEDICARE: MARY-ANTONETTE G MENTOR 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	073086	NY

General Provider Information

NPI Number	:	1053756551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY-ANTONETTE G MENTOR LCSW

Provider Business Mailing Address
First Line	:	220 MANHATTAN AVE APT 7L
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10025-2667
Country	:	US
Telephone Number	:	917-833-8084
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 MANHATTAN AVE APT 7L
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10025-2667
Country	:	US
Telephone Number	:	917-833-8084
Fax Number	:

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

Provider Enumeration Date	:	05/09/2013
Last Update Date	:	05/09/2013

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