Basic Information
| Provider Information | |||||||||
| NPI: | 1962171744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICCARDELLI | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 975 RENSSELAER AVE. | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9174033718 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7701 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112282413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182321351 | ||||||||
| FaxNumber: | 7182383862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2021 | ||||||||
| LastUpdateDate: | 09/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | NY | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 111560 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.