MEDICARE: IV LICENSED CLINICAL SOCIAL WORK P.C.

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center	069657	NY

General Provider Information

NPI Number	:	1295188076
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IV LICENSED CLINICAL SOCIAL WORK P.C.

Provider Business Mailing Address
First Line	:	4812 BEDFORD AVE
Second Line	:	APT 1A
City	:	BROOKLYN
State	:	NY
Zip	:	11235-8603
Country	:	US
Telephone Number	:	718-234-1212
Fax Number	:

Provider Business Practice Location Address
First Line	:	4812 BEDFORD AVE
Second Line	:	APT 1A
City	:	BROOKLYN
State	:	NY
Zip	:	11235-8603
Country	:	US
Telephone Number	:	718-234-1212
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. IRINA VOSKOBOYNIK
Credential	:	LCSW-R
Telephone Number	:	718-288-4770

Provider Enumeration Date	:	07/18/2016
Last Update Date	:	07/18/2016

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