MEDICARE: MRS. VIRGINIA STATLER 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	101YM0800X	Mental Health Counselor	R048720-1	NY

General Provider Information

NPI Number	:	1588726525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VIRGINIA STATLER LCSW

Provider Business Mailing Address
First Line	:	4250 VAN CORTLANDT PARK E
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10470-1951
Country	:	US
Telephone Number	:	914-513-7172
Fax Number	:

Provider Business Practice Location Address
First Line	:	4250 VAN CORTLANDT PARK E
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10470-1951
Country	:	US
Telephone Number	:	914-513-7172
Fax Number	:

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

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	07/08/2007

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