1356018790 NPI number — ERNESTO LIRA DE LA ROSA LICENSED PSYCHOLOGIST PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356018790 NPI number — ERNESTO LIRA DE LA ROSA LICENSED PSYCHOLOGIST PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ERNESTO LIRA DE LA ROSA LICENSED PSYCHOLOGIST PLLC
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:
1356018790
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
68 BRADHURST AVE APT 8G
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10039-3310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
352 7TH AVE FL 12A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10001-5893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-652-1148
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2021

Additional Information

Authorized Official

Authorized Official Last Name:
LIRA DE LA ROSA
Authorized Official First Name:
ERNESTO
Authorized Official Middle Name:
NOAM
Authorized Official Title or Position:
LICENSED CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
347-652-1148

Provider Taxonomy Codes

  • Taxonomy code: 103TC1900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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