MEDICARE: ALLYSA J WACHHOLDER 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	074310	NY

General Provider Information

NPI Number	:	1497787188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLYSA J WACHHOLDER LCSW

Provider Business Mailing Address
First Line	:	36 CLYMER ST
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-3913
Country	:	US
Telephone Number	:	631-828-6024
Fax Number	:

Provider Business Practice Location Address
First Line	:	36 CLYMER ST
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-3913
Country	:	US
Telephone Number	:	631-828-6024
Fax Number	:

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	07/08/2007

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