MEDICARE: MRS. GAYLE TOVA BOLLAG 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	078143	NY

General Provider Information

NPI Number	:	1649851023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GAYLE TOVA BOLLAG LCSW

Provider Business Mailing Address
First Line	:	30 VALLEY GREENS DR
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11581-3635
Country	:	US
Telephone Number	:	917-282-0453
Fax Number	:

Provider Business Practice Location Address
First Line	:	930 BROADWAY
Second Line	:
City	:	WOODMERE
State	:	NY
Zip	:	11598-1766
Country	:	US
Telephone Number	:	917-282-0453
Fax Number	:

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

Provider Enumeration Date	:	04/18/2021
Last Update Date	:	04/18/2021

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