MEDICARE: MS. AMY EITEN 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		NJ

General Provider Information

NPI Number	:	1790885226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AMY EITEN LCSW

Provider Business Mailing Address
First Line	:	736 ORANGEBURGH RD
Second Line	:
City	:	RIVERVALE
State	:	NJ
Zip	:	07675-6461
Country	:	US
Telephone Number	:	201-930-1340
Fax Number	:	201-930-1340

Provider Business Practice Location Address
First Line	:	65 N MAPLE AVE
Second Line	:	SUITE 220
City	:	RIDGEWOOD
State	:	NJ
Zip	:	07450-3233
Country	:	US
Telephone Number	:	201-930-1340
Fax Number	:	201-930-1340

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

Provider Enumeration Date	:	09/24/2006
Last Update Date	:	07/08/2007

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