MEDICARE: MAYA TRIFONOV SOCIAL WORKER

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	R047562-1	NY

General Provider Information

NPI Number	:	1528123205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYA TRIFONOV SOCIAL WORKER

Provider Business Mailing Address
First Line	:	1350 BAY RIDGE PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11228-2211
Country	:	US
Telephone Number	:	718-232-2657
Fax Number	:

Provider Business Practice Location Address
First Line	:	1350 BAY RIDGE PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11228-2211
Country	:	US
Telephone Number	:	718-232-2657
Fax Number	:

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

Provider Enumeration Date	:	12/24/2006
Last Update Date	:	07/08/2007

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