Basic Information
| Provider Information | |||||||||
| NPI: | 1366806705 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | QUEENS PSYCHOTHERAPY LCSW SERVICES P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9520 63RD RD | ||||||||
| Address2: | SUITE J | ||||||||
| City: | REGO PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113741160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184591225 | ||||||||
| FaxNumber: | 7184595805 | ||||||||
| Practice Location | |||||||||
| Address1: | 9520 63RD RD | ||||||||
| Address2: | SUITE J | ||||||||
| City: | REGO PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113741160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184591225 | ||||||||
| FaxNumber: | 7184595805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2016 | ||||||||
| LastUpdateDate: | 04/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | ACEVEDO | ||||||||
| AuthorizedOfficialFirstName: | VANESSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7184591225 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW-R | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.