MEDICARE: MS. JUDITH MYRNA WEISS 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	PR21955	NY

General Provider Information

NPI Number	:	1568536936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JUDITH MYRNA WEISS LCSW

Provider Business Mailing Address
First Line	:	47 E 87TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10128-1005
Country	:	US
Telephone Number	:	212-348-4274
Fax Number	:	718-351-4656

Provider Business Practice Location Address
First Line	:	1492 RICHMOND RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-2319
Country	:	US
Telephone Number	:	718-720-8169
Fax Number	:	718-351-4656

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

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	07/08/2007

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