MEDICARE: TWO MOUNTAINS THERAPY LCSW PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1912897885
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWO MOUNTAINS THERAPY LCSW PLLC

Provider Business Mailing Address
First Line	:	3210 30TH AVE # 2L
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11102-1562
Country	:	US
Telephone Number	:	929-244-3779
Fax Number	:

Provider Business Practice Location Address
First Line	:	3210 30TH AVE # 2L
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11102-1562
Country	:	US
Telephone Number	:	929-244-3779
Fax Number	:

Authorized Official
Title or Position	:	LCSW
Name	:	KEL MAISENBACHER
Credential	:
Telephone Number	:	929-244-3779

Provider Enumeration Date	:	07/03/2025
Last Update Date	:	07/03/2025

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