MEDICARE: MARIE SUZE DORMENA-DESRAVINE 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	0678681	NY

General Provider Information

NPI Number	:	1821297599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE SUZE DORMENA-DESRAVINE LMSW

Provider Business Mailing Address
First Line	:	1056 E 84TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-4228
Country	:	US
Telephone Number	:	718-531-3947
Fax Number	:

Provider Business Practice Location Address
First Line	:	1056 E 84TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-4228
Country	:	US
Telephone Number	:	718-531-3947
Fax Number	:

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

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

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Directions to “ MARIE SUZE DORMENA-DESRAVINE LMSW” Practice Location

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