MEDICARE: CARLOS DEMETRIO BRAVO GOGNY LCSW, MSW

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	076184	NY

General Provider Information

NPI Number	:	1528154671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLOS DEMETRIO BRAVO GOGNY LCSW, MSW

Provider Business Mailing Address
First Line	:	3265 JOHNSON AVE STE 214
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-3539
Country	:	US
Telephone Number	:	917-517-5010
Fax Number	:	718-548-0979

Provider Business Practice Location Address
First Line	:	3265 JOHNSON AVE STE 214
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-3539
Country	:	US
Telephone Number	:	917-517-5010
Fax Number	:	718-548-0979

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

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	04/03/2024

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