MEDICARE: MS. MAUREEN RIST MARCHESSAULT LCSW-R

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	044391-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	044391-1	OTHER		NYS LCSWR LICENSE

General Provider Information

NPI Number	:	1962494872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MAUREEN RIST MARCHESSAULT LCSW-R

Provider Business Mailing Address
First Line	:	21 ECHO VALLEY RD
Second Line	:
City	:	RED HOOK
State	:	NY
Zip	:	12571-2302
Country	:	US
Telephone Number	:	845-758-5955
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 ECHO VALLEY RD
Second Line	:
City	:	RED HOOK
State	:	NY
Zip	:	12571-2302
Country	:	US
Telephone Number	:	845-758-5955
Fax Number	:

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

Provider Enumeration Date	:	08/17/2005
Last Update Date	:	12/18/2007

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