MEDICARE: JANELLE T LAQUA LMSW

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	082181	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	082181	OTHER	NY	LMSW

General Provider Information

NPI Number	:	1790282325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANELLE T LAQUA LMSW

Provider Business Mailing Address
First Line	:	1780 OCEAN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-5401
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1780 OCEAN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-5401
Country	:	US
Telephone Number	:	718-758-7747
Fax Number	:

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

Provider Enumeration Date	:	04/10/2018
Last Update Date	:	04/10/2018

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