1114286101 NPI number — LCSW INTERVENTIONS FOR EMOTIONAL GROWTH, PC

Table of content: (NPI 1114286101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114286101 NPI number — LCSW INTERVENTIONS FOR EMOTIONAL GROWTH, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LCSW INTERVENTIONS FOR EMOTIONAL GROWTH, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1114286101
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14101 68TH DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
KEW GARDENS HILLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11367-1635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-520-0798
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14101 68TH DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
KEW GARDENS HILLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11367-1635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-520-0798
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BRIGNOLO
Authorized Official First Name:
MONICA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
718-520-0798

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  RO46222 , 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: 9865705 . This is a "AETNA PIN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 11699877 . This is a "CAQH UNIVERSAL CREDENTIALS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 274655 . This is a "MHN PIN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02864693 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000600019133 . This is a "HEALTH PLUS/ FAMILY HEALTH PLUS/ CHILD HEALTH PLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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