MEDICARE: TERAYNE THOMAS 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	104100000X	Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	838555284	OTHER	NY	DRIVERS LICENSE

General Provider Information

NPI Number	:	1639643091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERAYNE THOMAS MSW

Provider Business Mailing Address
First Line	:	216 ROCKAWAY AVE APT 14K
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11233-4236
Country	:	US
Telephone Number	:	718-785-7523
Fax Number	:

Provider Business Practice Location Address
First Line	:	216 ROCKAWAY AVE APT 14K
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11233-4236
Country	:	US
Telephone Number	:	718-785-7523
Fax Number	:

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

Provider Enumeration Date	:	01/17/2019
Last Update Date	:	01/17/2019

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