MEDICARE: MR. MARTIN JOSEPH BLONDELL 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	R032679	NY

General Provider Information

NPI Number	:	1851455760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARTIN JOSEPH BLONDELL LCSW

Provider Business Mailing Address
First Line	:	3974 AMBOY RD
Second Line	:	SUITE 306
City	:	STATEN ISLAND
State	:	NY
Zip	:	10308-2414
Country	:	US
Telephone Number	:	718-967-4919
Fax Number	:	718-317-8898

Provider Business Practice Location Address
First Line	:	3974 AMBOY RD
Second Line	:	SUITE 306
City	:	STATEN ISLAND
State	:	NY
Zip	:	10308-2414
Country	:	US
Telephone Number	:	718-967-4919
Fax Number	:	718-317-8898

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

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	07/08/2007

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