MEDICARE: KELLY LINDA ERICKSON-JORGE 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	104100000X	Social Worker	079786	NY

General Provider Information

NPI Number	:	1063940807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LINDA ERICKSON-JORGE LMSW

Provider Business Mailing Address
First Line	:	248 W 35TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10001-2505
Country	:	US
Telephone Number	:	718-681-8700
Fax Number	:	646-380-1322

Provider Business Practice Location Address
First Line	:	459 E 149TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-1314
Country	:	US
Telephone Number	:	855-681-8700
Fax Number	:	646-380-1322

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

Provider Enumeration Date	:	05/24/2017
Last Update Date	:	05/24/2017

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