MEDICARE: MR. WILLIAM PATRICK FENTY II 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	054186R	NY

General Provider Information

NPI Number	:	1730303454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM PATRICK FENTY II LCSW

Provider Business Mailing Address
First Line	:	31 MELROSE RD
Second Line	:
City	:	DIX HILLS
State	:	NY
Zip	:	11746-5610
Country	:	US
Telephone Number	:	631-425-1168
Fax Number	:	631-673-0313

Provider Business Practice Location Address
First Line	:	31 MELROSE RD
Second Line	:
City	:	DIX HILLS
State	:	NY
Zip	:	11746-5610
Country	:	US
Telephone Number	:	631-425-1168
Fax Number	:	631-673-0313

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

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	07/08/2007

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