Basic Information
| Provider Information | |||||||||
| NPI: | 1003471152 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GARDEN CITY THERAPY, LCSW, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 1ST ST APT 4J | ||||||||
| Address2: | |||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115014002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168161511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 233 7TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115305747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168282622 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2019 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | AMBALU | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5168161511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.