MEDICARE: MS. EVELIA MARGARITA SANTIAGO-GOMEZ LCSWR

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	R052184	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	052184-1	OTHER	NY	LCSWR LICENSE

General Provider Information

NPI Number	:	1922090760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. EVELIA MARGARITA SANTIAGO-GOMEZ LCSWR

Provider Business Mailing Address
First Line	:	2519 BRUYNSWICK RD
Second Line	:
City	:	WALLKILL
State	:	NY
Zip	:	12589-3244
Country	:	US
Telephone Number	:	845-476-9800
Fax Number	:

Provider Business Practice Location Address
First Line	:	2519 BRUYNSWICK RD
Second Line	:
City	:	WALLKILL
State	:	NY
Zip	:	12589-3244
Country	:	US
Telephone Number	:	845-476-9800
Fax Number	:	845-744-6793

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

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	04/27/2012

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