Basic Information
| Provider Information | |||||||||
| NPI: | 1578635777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOBLE | ||||||||
| FirstName: | MYRNA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 SAMPSON AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104652912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144268857 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4123 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104576222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182993045 | ||||||||
| FaxNumber: | 7187162604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 065924 | NY | X | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 075618 | NY | X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 136167177 | 01 | NY | FIDELIS NUMBER | OTHER |