Basic Information
| Provider Information | |||||||||
| NPI: | 1174079024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAMORRO | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4419 3RD AVENUE GUIDANCE CENTER | ||||||||
| Address2: | SUITE 1A | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183647700 | ||||||||
| FaxNumber: | 7183641513 | ||||||||
| Practice Location | |||||||||
| Address1: | 4419 3RD AVE | ||||||||
| Address2: | SUITE 1A | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104572562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183647700 | ||||||||
| FaxNumber: | 7183641513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2016 | ||||||||
| LastUpdateDate: | 08/31/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 087891 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1528082013 | 05 | NY | MEDICAID |