MEDICARE: JOHN TAVOLACCI 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	069437-1	NY

General Provider Information

NPI Number	:	1750823506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN TAVOLACCI LCSW

Provider Business Mailing Address
First Line	:	207 HOWARD ST
Second Line	:
City	:	EAST WILLISTON
State	:	NY
Zip	:	11596-1421
Country	:	US
Telephone Number	:	917-584-7068
Fax Number	:	212-361-3761

Provider Business Practice Location Address
First Line	:	120 WALL ST
Second Line	:	17TH FLOOR
City	:	NEW YORK
State	:	NY
Zip	:	10005-3904
Country	:	US
Telephone Number	:	212-361-1622
Fax Number	:	212-361-3761

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

Provider Enumeration Date	:	11/10/2016
Last Update Date	:	11/10/2016

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