MEDICARE: MRS. ETTA ANSEL RCSW

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	R014929-1	NY

General Provider Information

NPI Number	:	1902118193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ETTA ANSEL RCSW

Provider Business Mailing Address
First Line	:	5 SPRING ROCK PL
Second Line	:
City	:	SPRING VALLEY
State	:	NY
Zip	:	10977-1715
Country	:	US
Telephone Number	:	917-656-6216
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 SPRING ROCK PL
Second Line	:
City	:	SPRING VALLEY
State	:	NY
Zip	:	10977-1715
Country	:	US
Telephone Number	:	917-656-6216
Fax Number	:

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

Provider Enumeration Date	:	07/05/2010
Last Update Date	:	07/05/2010

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