MEDICARE: MRS. KATHLEEN BRONNER FIKS 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	R006078	NY
2	1041C0700X	Clinical Social Worker	44SC00090300	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	053065	OTHER	MHS VALUE OPTIONS
2	P582628	OTHER	OXFORD
3	7485794V	OTHER	VALUE BEHAVIRAL
4	0082408	OTHER	GHI

General Provider Information

NPI Number	:	1881794907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHLEEN BRONNER FIKS LCSW

Provider Business Mailing Address
First Line	:	83 GLENWOOD RD
Second Line	:
City	:	TENAFLY
State	:	NJ
Zip	:	07670-1135
Country	:	US
Telephone Number	:	201-569-1819
Fax Number	:	201-568-4494

Provider Business Practice Location Address
First Line	:	10848 70TH RD
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-3961
Country	:	US
Telephone Number	:	718-261-3696
Fax Number	:	201-568-4494

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

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/08/2007

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