MEDICARE: MRS. JOHANNA CRESWELL BAEZ 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	079144-1	NY

General Provider Information

NPI Number	:	1104194976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOHANNA CRESWELL BAEZ LCSW

Provider Business Mailing Address
First Line	:	370 CONVENT AVE APT 1A
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10031
Country	:	US
Telephone Number	:	646-481-0185
Fax Number	:

Provider Business Practice Location Address
First Line	:	370 CONVENT AVE APT 1A
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10031-4224
Country	:	US
Telephone Number	:	646-481-0185
Fax Number	:

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

Provider Enumeration Date	:	12/08/2011
Last Update Date	:	12/08/2011

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