MEDICARE: GAVIA LIFECARE CENTER, LLC

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
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1710592209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GAVIA LIFECARE CENTER, LLC

Provider Business Mailing Address
First Line	:	1343 LONG POND RD STE A
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14626-2913
Country	:	US
Telephone Number	:	585-371-6464
Fax Number	:	585-371-6464

Provider Business Practice Location Address
First Line	:	1343 LONG POND RD STE A
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14626-2913
Country	:	US
Telephone Number	:	585-371-6464
Fax Number	:	585-371-6464

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. SHERRY L. NAU
Credential	:	ED.D, LCSW
Telephone Number	:	585-371-6464

Provider Enumeration Date	:	09/10/2020
Last Update Date	:	04/22/2021

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