MEDICARE: MS. LISA MASTER 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	R0388551	NY

General Provider Information

NPI Number	:	1093805277
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA MASTER LCSW

Provider Business Mailing Address
First Line	:	117 WEST 13TH ST
Second Line	:	#1
City	:	NEW YORK
State	:	NY
Zip	:	10011-7832
Country	:	US
Telephone Number	:	212-243-7177
Fax Number	:

Provider Business Practice Location Address
First Line	:	117 WEST 13TH ST
Second Line	:	#1
City	:	NEW YORK
State	:	NY
Zip	:	10011-7832
Country	:	US
Telephone Number	:	212-243-7177
Fax Number	:

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

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	07/08/2007

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