Basic Information
| Provider Information | |||||||||
| NPI: | 1558987156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RASIC-REDZEMATOVIC | ||||||||
| FirstName: | ENA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9777 QUEENS BLVD PH | ||||||||
| Address2: | |||||||||
| City: | REGO PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113743300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188969090 | ||||||||
| FaxNumber: | 7188300724 | ||||||||
| Practice Location | |||||||||
| Address1: | 9777 QUEENS BLVD PH | ||||||||
| Address2: | |||||||||
| City: | REGO PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113743300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188969090 | ||||||||
| FaxNumber: | 7188300724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2020 | ||||||||
| LastUpdateDate: | 06/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.