Healthcare Provider Details

I. General information

NPI: 1811755820
Provider Name (Legal Business Name): MSG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 CLAFLIN AVE APT 602
BRONX NY
10468-2228
US

IV. Provider business mailing address

234 EVERETT PL
ENGLEWOOD NJ
07631-1660
US

V. Phone/Fax

Practice location:
  • Phone: 646-338-2133
  • Fax:
Mailing address:
  • Phone: 646-338-2133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL STEVEN GONZALEZ
Title or Position: MENTAL HEALTH THERAPIST
Credential: LCSW
Phone: 646-338-2133