MEDICARE: JACQULINE LUTCHMIDAT

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	72 071683	NY

General Provider Information

NPI Number	:	1497108476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQULINE LUTCHMIDAT

Provider Business Mailing Address
First Line	:	100 GREEN ST
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11580-5014
Country	:	US
Telephone Number	:	516-285-1221
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 GREEN ST
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11580-5014
Country	:	US
Telephone Number	:	516-285-1221
Fax Number	:

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

Provider Enumeration Date	:	07/14/2016
Last Update Date	:	07/14/2016

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Directions to “ JACQULINE LUTCHMIDAT ” Practice Location

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