Basic Information
| Provider Information | |||||||||
| NPI: | 1093868770 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LINCOLN MEDICAL AND MENTAL HELATH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2999 FREDERICK DOUGLASS BLVD | ||||||||
| Address2: | #25K | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100391320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175393563 | ||||||||
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| Practice Location | |||||||||
| Address1: | 234 E 149TH ST | ||||||||
| Address2: | SOCIAL WORK DEPT. RM 1B2 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104515504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185795657 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | TANISHA | ||||||||
| AuthorizedOfficialMiddleName: | NICOLE | ||||||||
| AuthorizedOfficialTitleorPosition: | SOCIAL WORK SUPERVISOR II | ||||||||
| AuthorizedOfficialTelephone: | 7185795657 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 072986 | NY | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 072986 | 01 | NY | LCSW-SOCIAL WORK | OTHER |