Basic Information
Provider Information | |||||||||
NPI: | 1326102575 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | URENO | ||||||||
FirstName: | SERGIO | ||||||||
MiddleName: | ROMAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH. D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5800 3RD AVE | ||||||||
Address2: | MANAGED CARE DEPARTMENT | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112203702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7186307477 | ||||||||
FaxNumber: | 7186307437 | ||||||||
Practice Location | |||||||||
Address1: | 514 49TH ST | ||||||||
Address2: | LUTHERAN FHC SUNSET TERRACE | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112202010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7188541851 | ||||||||
FaxNumber: | 7184358510 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2006 | ||||||||
LastUpdateDate: | 08/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 016031 | NY | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.