Basic Information
| Provider Information | |||||||||
| NPI: | 1942547989 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MERCER | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | DENISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 W 125TH ST FL 10 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100274516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128644128 | ||||||||
| FaxNumber: | 2128647987 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 W 125TH ST FL 10 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100274516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128644128 | ||||||||
| FaxNumber: | 2128647987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2013 | ||||||||
| LastUpdateDate: | 01/10/2013 | ||||||||
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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 | 101YA0400X | 16719 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 132759323 | 05 | NY | MEDICAID |