Basic Information
| Provider Information | |||||||||
| NPI: | 1558683912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINAKAN | ||||||||
| FirstName: | RIESA | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MINAKAN | ||||||||
| OtherFirstName: | RIESA | ||||||||
| OtherMiddleName: | PROMOTE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6 GRAMATAN AVE | ||||||||
| Address2: | C/O WJCS | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105503208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146688938 | ||||||||
| FaxNumber: | 9146682545 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 GRAMATAN AVE | ||||||||
| Address2: | C/O WJCS | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105503208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146688938 | ||||||||
| FaxNumber: | 9146682545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2010 | ||||||||
| LastUpdateDate: | 06/20/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 083778 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 004235918 | 05 | CT | MEDICAID |