Basic Information
| Provider Information | |||||||||
| NPI: | 1356746515 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOKLYN PSYCHOTHERAPY, LCSW, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROOKLYN PSYCHOTHERAPY, PC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 148 WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112378042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3474748464 | ||||||||
| FaxNumber: | 3476300519 | ||||||||
| Practice Location | |||||||||
| Address1: | 148 WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112378042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3474748464 | ||||||||
| FaxNumber: | 3476300519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2014 | ||||||||
| LastUpdateDate: | 11/27/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COSTA | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3474748464 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 081378 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.