1063053916 NPI number — ESSENTIAL COUNSELING WELLNESS LCSW PLLC

Table of content: (NPI 1063053916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063053916 NPI number — ESSENTIAL COUNSELING WELLNESS LCSW PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ESSENTIAL COUNSELING WELLNESS LCSW 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:
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NPI Number Information

NPI Number:
1063053916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
583 5TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11215-3503
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:
99 WALL ST STE 580
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:
10005-4301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-405-6352
Provider Business Practice Location Address Fax Number:
646-767-0539
Provider Enumeration Date:
10/02/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BLACKBURN
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
DOUGLAS
Authorized Official Title or Position:
CEO/THERAPIST
Authorized Official Telephone Number:
347-460-1305

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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