MEDICARE: MARIEL CHLOE PRACTICE LLC

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	104100000X	Social Worker	73083458	NY

General Provider Information

NPI Number	:	1457722431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIEL CHLOE PRACTICE LLC

Provider Business Mailing Address
First Line	:	330 E 79TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10075-0966
Country	:	US
Telephone Number	:	917-553-1870
Fax Number	:

Provider Business Practice Location Address
First Line	:	330 E 79TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10075-0966
Country	:	US
Telephone Number	:	917-553-1870
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MARIEL CHLOE MANGOLD
Credential	:	LCSW
Telephone Number	:	917-553-1870

Provider Enumeration Date	:	10/15/2015
Last Update Date	:	10/15/2015

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