MEDICARE: MS. SHELLY DAVIDOR 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	104100000X	Social Worker

General Provider Information

NPI Number	:	1780875203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHELLY DAVIDOR LCSW

Provider Business Mailing Address
First Line	:	255 15TH ST
Second Line	:	SUITE 103, BASEMENT LEVEL
City	:	BROOKLYN
State	:	NY
Zip	:	11215-4988
Country	:	US
Telephone Number	:	718-788-5101
Fax Number	:

Provider Business Practice Location Address
First Line	:	255 15TH ST
Second Line	:	SUITE 103, BASEMENT LEVEL
City	:	BROOKLYN
State	:	NY
Zip	:	11215-4988
Country	:	US
Telephone Number	:	718-788-5101
Fax Number	:

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

Provider Enumeration Date	:	08/08/2007
Last Update Date	:	07/13/2012

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