MEDICARE: MS. JEAN DAVIS LCAT, ATR-BC

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	221700000X	Art Therapist	000113-1	NY

General Provider Information

NPI Number	:	1194000760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JEAN DAVIS LCAT, ATR-BC

Provider Business Mailing Address
First Line	:	757 E 19TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-1807
Country	:	US
Telephone Number	:	917-292-9301
Fax Number	:

Provider Business Practice Location Address
First Line	:	757 E 19TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-1807
Country	:	US
Telephone Number	:	917-292-9301
Fax Number	:

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

Provider Enumeration Date	:	10/14/2011
Last Update Date	:	10/14/2011

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