MEDICARE: COME TO THE TABLE COUNSELING 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093319576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COME TO THE TABLE COUNSELING LCSW

Provider Business Mailing Address
First Line	:	4097 WILSON RD E
Second Line	:
City	:	TABERG
State	:	NY
Zip	:	13471-2037
Country	:	US
Telephone Number	:	315-335-9727
Fax Number	:

Provider Business Practice Location Address
First Line	:	40 MAIN ST LOWR
Second Line	:
City	:	CAMDEN
State	:	NY
Zip	:	13316-1302
Country	:	US
Telephone Number	:	315-335-9727
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOTHERAPIST/OWNER
Name	:	MRS. JESSICA M PERUSSE
Credential	:	LCSW-R
Telephone Number	:	315-335-9727

Provider Enumeration Date	:	11/25/2020
Last Update Date	:	11/25/2020

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Directions to “COME TO THE TABLE COUNSELING LCSW ” Practice Location

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