Basic Information
| Provider Information | |||||||||
| NPI: | 1760845069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUMMERS | ||||||||
| FirstName: | DEIDRE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | 092131 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SUMMERS | ||||||||
| OtherFirstName: | DEIDRE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | 20397 | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 125 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100042400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123852380 | ||||||||
| FaxNumber: | 2123852380 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 BROAD STREET | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123853030 | ||||||||
| FaxNumber: | 2123852380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2016 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 092131 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.