Basic Information
| Provider Information | |||||||||
| NPI: | 1700304250 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHEN | ||||||||
| FirstName: | CHEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 506 W 122ND ST APT 4 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100275850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9293719805 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14015B SANFORD AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113552557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183588288 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2017 | ||||||||
| LastUpdateDate: | 12/21/2017 | ||||||||
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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 | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 102306-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 348629715 | 01 | NY | LEARNER PERMIT | OTHER | 16241055020638 | 01 | NY | NYC IDENTIFICATION CARD | OTHER | YSC1790126970 | 01 | NY | EMPLOYMENT AUTHORIZATION CARD | OTHER |