MEDICARE: AVERY RADCLYFFE KLOTSCHE 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	104100000X	Social Worker

General Provider Information

NPI Number	:	1699286005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AVERY RADCLYFFE KLOTSCHE LCSW

Provider Business Mailing Address
First Line	:	226 PROSPECT PARK W # 186
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11215-5802
Country	:	US
Telephone Number	:	929-379-0220
Fax Number	:

Provider Business Practice Location Address
First Line	:	226 PROSPECT PARK W # 186
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11215-5802
Country	:	US
Telephone Number	:	929-379-0220
Fax Number	:

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

Provider Enumeration Date	:	10/12/2017
Last Update Date	:	05/12/2021

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