Basic Information
| Provider Information | |||||||||
| NPI: | 1215464631 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY COUNSELING AND MEDIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 W 31ST ST | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100013596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125646006 | ||||||||
| FaxNumber: | 2125643440 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 W 31ST ST | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100013596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125646006 | ||||||||
| FaxNumber: | 2125643440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2017 | ||||||||
| LastUpdateDate: | 05/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | TANNEBERGER | ||||||||
| AuthorizedOfficialFirstName: | MARY TANNEBERGER | ||||||||
| AuthorizedOfficialMiddleName: | AGNES | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7185964991 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW-R | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | R035238-1 | NY | Y | Agencies | Community/Behavioral Health |
No ID Information.