1760511554 NPI number — FERN DEBRA SIMON LCSW-R

Table of content: FERN DEBRA SIMON LCSW-R (NPI 1760511554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760511554 NPI number — FERN DEBRA SIMON LCSW-R

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMON
Provider First Name:
FERN
Provider Middle Name:
DEBRA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW-R
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760511554
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
732 GLOVER PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALDWIN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11510-3505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-546-0102
Provider Business Mailing Address Fax Number:
516-546-2684

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
732 GLOVER PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALDWIN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11510-3505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-546-0102
Provider Business Practice Location Address Fax Number:
516-546-2684
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  R045230-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 290-902000 . This is a "MAGELLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: A349806 . This is a "VALUE OPTIONS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7373255 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7481514 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 225747586 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P2063316 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: N7B721 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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