Basic Information
Provider Information | |||||||||
NPI: | 1093154940 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PEDLEY | ||||||||
FirstName: | NEIL | ||||||||
MiddleName: | OLIVER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2701 38TH AVE | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | LONG ISLAND CITY | ||||||||
State: | NY | ||||||||
PostalCode: | 111012603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7183600938 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 14410 JAMAICA AVE | ||||||||
Address2: |   | ||||||||
City: | JAMAICA | ||||||||
State: | NY | ||||||||
PostalCode: | 114353624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7182061990 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2013 | ||||||||
LastUpdateDate: | 06/24/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 087773 | NY | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 1396822839 | 05 | NY |   | MEDICAID |