Basic Information
| Provider Information | |||||||||
| NPI: | 1598362212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GENOA | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2277 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | BALDWIN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115103148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163775400 | ||||||||
| FaxNumber: | 5163775490 | ||||||||
| Practice Location | |||||||||
| Address1: | 2277 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | BALDWIN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115103148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163775400 | ||||||||
| FaxNumber: | 5163775490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2020 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 109942 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.