MEDICARE: SUZANNE D'AVERSA 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	019126	NY

General Provider Information

NPI Number	:	1770546814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE D'AVERSA LCSW

Provider Business Mailing Address
First Line	:	PO BOX 3764
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12203-0764
Country	:	US
Telephone Number	:	518-221-6554
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 PINNACLE PL
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12203-3496
Country	:	US
Telephone Number	:	518-221-6554
Fax Number	:

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

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	12/18/2009

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