MEDICARE: MRS. GABRIELLE TELLER LMSW

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	080887-1	NY

General Provider Information

NPI Number	:	1316100399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GABRIELLE TELLER LMSW

Provider Business Mailing Address
First Line	:	520 JARVIS AVE
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-5426
Country	:	US
Telephone Number	:	917-291-3490
Fax Number	:

Provider Business Practice Location Address
First Line	:	156 BEACH 9TH ST
Second Line	:	SUITE C
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-5636
Country	:	US
Telephone Number	:	347-695-9700
Fax Number	:	347-697-9701

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

Provider Enumeration Date	:	07/09/2008
Last Update Date	:	05/17/2011

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