Basic Information
Provider Information | |||||||||
NPI: | 1508227265 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VERNON | ||||||||
FirstName: | WALTER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VERNON | ||||||||
OtherFirstName: | WALTER | ||||||||
OtherMiddleName: | HUDSON | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 435 WEBSTER AVE APT 6PH | ||||||||
Address2: |   | ||||||||
City: | NEW ROCHELLE | ||||||||
State: | NY | ||||||||
PostalCode: | 10801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7188842992 | ||||||||
FaxNumber: | 7188842901 | ||||||||
Practice Location | |||||||||
Address1: | 435 WEBSTER AVE APT 6PH | ||||||||
Address2: |   | ||||||||
City: | NEW ROCHELLE | ||||||||
State: | NY | ||||||||
PostalCode: | 10801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7188842992 | ||||||||
FaxNumber: | 7188842901 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2016 | ||||||||
LastUpdateDate: | 03/09/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | NYCPS-P388 | NY | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 131930700 | 01 | NY | RIVERDALE MENTAL HEALTH ASSOCIATION | OTHER |