MEDICARE: BORIS THOMAS PHD, 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	149-010219	IL
2	1041C0700X	Clinical Social Worker	081412-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	149-01029	OTHER	IL	IL LCSW LIC NO.
2	01632700	OTHER	IL	BLUECROSSBLUESHIELD NO.
3	480484	OTHER	IL	VALUE OPTIONS PROVIDER NO
4	R-081412-1	OTHER	NY	NY LCSW

General Provider Information

NPI Number	:	1427128859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BORIS THOMAS PHD, LCSW

Provider Business Mailing Address
First Line	:	603 W 115TH ST # 253
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10025-7722
Country	:	US
Telephone Number	:	312-279-7575
Fax Number	:

Provider Business Practice Location Address
First Line	:	303 5TH AVE STE 602
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10016-6601
Country	:	US
Telephone Number	:	917-224-3855
Fax Number	:

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

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	10/25/2015

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