MEDICARE: MONA WAKELEY-FISHMAN 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	075918	NY

General Provider Information

NPI Number	:	1871649293
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONA WAKELEY-FISHMAN LCSW

Provider Business Mailing Address
First Line	:	4136 27TH ST
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-3825
Country	:	US
Telephone Number	:	718-389-5100
Fax Number	:

Provider Business Practice Location Address
First Line	:	4136 27TH ST
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-3825
Country	:	US
Telephone Number	:	718-389-5100
Fax Number	:

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

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	10/07/2016

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