MEDICARE: MRS. DELSA JOHNSON FAUCONIER 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	0754161	NY

General Provider Information

NPI Number	:	1154572469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DELSA JOHNSON FAUCONIER LCSW

Provider Business Mailing Address
First Line	:	97 BUSH AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10303-2215
Country	:	US
Telephone Number	:	718-614-3363
Fax Number	:

Provider Business Practice Location Address
First Line	:	1953 RICHMOND TER
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-1201
Country	:	US
Telephone Number	:	718-614-3363
Fax Number	:

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

Provider Enumeration Date	:	10/06/2008
Last Update Date	:	01/21/2009

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