MEDICARE: MR. SHANE MARK TULL 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	074557	NY

General Provider Information

NPI Number	:	1306857230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SHANE MARK TULL LCSW

Provider Business Mailing Address
First Line	:	549 THROOP AVE
Second Line	:	3F
City	:	BROOKLYN
State	:	NY
Zip	:	11216-2434
Country	:	US
Telephone Number	:	947-884-4135
Fax Number	:	718-576-9424

Provider Business Practice Location Address
First Line	:	549 THROOP AVE
Second Line	:	3F
City	:	BROOKLYN
State	:	NY
Zip	:	11216-2434
Country	:	US
Telephone Number	:	947-884-4135
Fax Number	:	718-576-9424

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

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	04/12/2013

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