MEDICARE: MR. JOSEPH ANTHONY DEVIVO 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	R034622-1	NY
2	1041C0700X	Clinical Social Worker	44SC00035700	NJ

General Provider Information

NPI Number	:	1538303367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSEPH ANTHONY DEVIVO LCSW

Provider Business Mailing Address
First Line	:	645 FOREST AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10310-2517
Country	:	US
Telephone Number	:	718-720-9233
Fax Number	:

Provider Business Practice Location Address
First Line	:	645 FOREST AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10310-2517
Country	:	US
Telephone Number	:	718-720-9233
Fax Number	:

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

Provider Enumeration Date	:	04/23/2009
Last Update Date	:	04/27/2013

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