1710929203 NPI number — INNOVATIVE SOCIAL WORK SERVICES, PC

Table of content: (NPI 1710929203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710929203 NPI number — INNOVATIVE SOCIAL WORK SERVICES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE SOCIAL WORK SERVICES, 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:
1710929203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
596 E 165TH ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10456-6849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-620-7366
Provider Business Mailing Address Fax Number:
718-893-1635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
596 E 165TH ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10456-6849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-620-7366
Provider Business Practice Location Address Fax Number:
718-893-1635
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BALTHROPE
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
718-620-7366

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  R057551 , 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: 162213P . This is a "HIP (INSURANCE CO)" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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