MEDICARE: LCSW INTERVENTIONS FOR EMOTIONAL GROWTH, PC

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	RO46222	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9865705	OTHER	NY	AETNA PIN
2	11699877	OTHER	NY	CAQH UNIVERSAL CREDENTIALS
3	274655	OTHER	NY	MHN PIN
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	000600019133	OTHER	NY	HEALTH PLUS/ FAMILY HEALTH PLUS/ CHILD HEALTH PLUS

General Provider Information

NPI Number	:	1114286101
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LCSW INTERVENTIONS FOR EMOTIONAL GROWTH, PC

Provider Business Mailing Address
First Line	:	14101 68TH DR
Second Line	:	SUITE A
City	:	KEW GARDENS HILLS
State	:	NY
Zip	:	11367-1635
Country	:	US
Telephone Number	:	718-520-0798
Fax Number	:

Provider Business Practice Location Address
First Line	:	14101 68TH DR
Second Line	:	SUITE A
City	:	KEW GARDENS HILLS
State	:	NY
Zip	:	11367-1635
Country	:	US
Telephone Number	:	718-520-0798
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MONICA BRIGNOLO
Credential	:	LCSW
Telephone Number	:	718-520-0798

Provider Enumeration Date	:	05/10/2012
Last Update Date	:	05/10/2012

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