MEDICARE: SHIMON DREYFUSS MHC

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	103TS0200X	School Psychologist		NY

General Provider Information

NPI Number	:	1598714149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIMON DREYFUSS MHC

Provider Business Mailing Address
First Line	:	813 QUENTIN RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11223-2251
Country	:	US
Telephone Number	:	718-787-4412
Fax Number	:

Provider Business Practice Location Address
First Line	:	813 QUENTIN RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11223-2251
Country	:	US
Telephone Number	:	718-787-4412
Fax Number	:

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

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	11/15/2010

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