MEDICARE: MS. LOIS MERGENTIME 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	PR024991-1	NY

General Provider Information

NPI Number	:	1124035852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LOIS MERGENTIME LCSW

Provider Business Mailing Address
First Line	:	272 PIERMONT AVE
Second Line	:
City	:	NYACK
State	:	NY
Zip	:	10960-4663
Country	:	US
Telephone Number	:	845-353-0890
Fax Number	:	845-267-2173

Provider Business Practice Location Address
First Line	:	271 S BROADWAY
Second Line	:
City	:	NYACK
State	:	NY
Zip	:	10960-4636
Country	:	US
Telephone Number	:	845-641-9595
Fax Number	:	845-267-2173

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

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	04/23/2017

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