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NPI Code Detail

MEDICARE: MS. AMANDA WAGERIK-FASANO LMSW, CASAC-T

MEDICARE: MS. AMANDA WAGERIK-FASANO LMSW, CASAC-T
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
1174400000XSpecialist

General Provider Information

NPI Number : 1750659215
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. AMANDA WAGERIK-FASANO LMSW, CASAC-T
Provider Business Mailing Address
First Line : 3911 RICHMOND AVE
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10312-5110
Country : US
Telephone Number : 718-948-3232
Fax Number : 718-966-6605
Provider Business Practice Location Address
First Line : 3911 RICHMOND AVE
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10312-5110
Country : US
Telephone Number : 718-948-3232
Fax Number : 718-966-6605
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/12/2011
Last Update Date : 05/08/2019

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