MEDICARE: DR. THOMAS RICHARD ZASTOWNY PHD

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	103TA0400X	Addiction (Substance Use Disorder) Psychologist	007889	NY
2	103TB0200X	Cognitive & Behavioral Psychologist	007889	NY

General Provider Information

NPI Number	:	1376734707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS RICHARD ZASTOWNY PHD

Provider Business Mailing Address
First Line	:	1513 SOUTH AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14620-2926
Country	:	US
Telephone Number	:	585-787-1560
Fax Number	:	585-787-1560

Provider Business Practice Location Address
First Line	:	1513 SOUTH AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14620-2926
Country	:	US
Telephone Number	:	585-787-1560
Fax Number	:	585-787-1560

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

Provider Enumeration Date	:	08/09/2007
Last Update Date	:	08/09/2007

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