Basic Information
| Provider Information | |||||||||
| NPI: | 1962097733 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEACOCK | ||||||||
| FirstName: | CHELSEA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 91-14 37TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | JACKSON HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187791600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 91-14 37TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | JACKSON HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187791600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2021 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 083603 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.