MEDICARE: GENETT ANDREA TOMKO MSW, LCSW, IMH-E III

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	LCSW-12770	AZ

General Provider Information

NPI Number	:	1467783340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENETT ANDREA TOMKO MSW, LCSW, IMH-E III

Provider Business Mailing Address
First Line	:	6409 S DORSEY LN
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85283-3910
Country	:	US
Telephone Number	:	480-650-0209
Fax Number	:

Provider Business Practice Location Address
First Line	:	825 W WARNER RD
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85225-2926
Country	:	US
Telephone Number	:	480-650-0209
Fax Number	:

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

Provider Enumeration Date	:	01/17/2010
Last Update Date	:	01/17/2010

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