Healthcare Provider Details

I. General information

NPI: 1023359536
Provider Name (Legal Business Name): LYNN BRODER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2013
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2277 GRAND AVE
BALDWIN NY
11510-3148
US

IV. Provider business mailing address

2277 GRAND AVENUE
BALDWIN NY
11510
US

V. Phone/Fax

Practice location:
  • Phone: 516-377-5000
  • Fax: 516-377-5490
Mailing address:
  • Phone: 516-377-5400
  • Fax: 516-377-5490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number058764-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: