MEDICARE: MR. NICK A GOREVIC 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	1041C0700X	Clinical Social Worker	5880477	NY

General Provider Information

NPI Number	:	1790845634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NICK A GOREVIC LMSW

Provider Business Mailing Address
First Line	:	115 4TH AVE APT 5G
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10003-4908
Country	:	US
Telephone Number	:	646-594-8601
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 FLATBUSH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-3521
Country	:	US
Telephone Number	:	718-377-5755
Fax Number	:

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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