MEDICARE: MR. STEPHAN K KOBLICK MSW

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	PRO15480-1	NY

General Provider Information

NPI Number	:	1912951484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STEPHAN K KOBLICK MSW

Provider Business Mailing Address
First Line	:	71 BEAUMONT ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-4103
Country	:	US
Telephone Number	:	718-439-4337
Fax Number	:	718-439-4340

Provider Business Practice Location Address
First Line	:	40 FLATBUSH AVENUE EXT
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11201-1906
Country	:	US
Telephone Number	:	718-439-4337
Fax Number	:	718-439-4340

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

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	07/08/2007

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