MEDICARE: GINA ANN CONDURSO 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	078843-1	NY

General Provider Information

NPI Number	:	1518201011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA ANN CONDURSO LCSW

Provider Business Mailing Address
First Line	:	1650 SYCAMORE AVE
Second Line	:	SUITE 39
City	:	BOHEMIA
State	:	NY
Zip	:	11716-1738
Country	:	US
Telephone Number	:	631-758-8290
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 SYCAMORE AVE
Second Line	:	SUITE 39
City	:	BOHEMIA
State	:	NY
Zip	:	11716-1738
Country	:	US
Telephone Number	:	631-758-8290
Fax Number	:

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

Provider Enumeration Date	:	11/21/2012
Last Update Date	:	11/21/2012

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