MEDICARE: CHANA A. DERSHOWITZ 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	44SC05775700	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	44SC05775700	OTHER	NJ	LICENSED CLINICAL SOCIAL WORKER

General Provider Information

NPI Number	:	1912493024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANA A. DERSHOWITZ LCSW

Provider Business Mailing Address
First Line	:	36 KEW GARDENS DR
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-7102
Country	:	US
Telephone Number	:	732-942-0886
Fax Number	:

Provider Business Practice Location Address
First Line	:	545 E COUNTY LINE RD STE 17A
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-1487
Country	:	US
Telephone Number	:	732-330-6191
Fax Number	:

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

Provider Enumeration Date	:	07/02/2018
Last Update Date	:	07/02/2018

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