MEDICARE: YAJAIRA A VASCO 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	44SC05521900	NJ
2	251S00000X	Community/Behavioral Health Agency	44SC05521900	NJ

General Provider Information

NPI Number	:	1316368970
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YAJAIRA A VASCO LCSW

Provider Business Mailing Address
First Line	:	7101 KENNEDY BLVD
Second Line	:
City	:	NORTH BERGEN
State	:	NJ
Zip	:	07047-3934
Country	:	US
Telephone Number	:	201-854-0500
Fax Number	:

Provider Business Practice Location Address
First Line	:	7101 KENNEDY BLVD
Second Line	:
City	:	NORTH BERGEN
State	:	NJ
Zip	:	07047-3934
Country	:	US
Telephone Number	:	201-854-0500
Fax Number	:

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

Provider Enumeration Date	:	12/30/2013
Last Update Date	:	12/30/2013

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