Healthcare Provider Details

I. General information

NPI: 1063940807
Provider Name (Legal Business Name): KELLY LINDA ERICKSON-JORGE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 05/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 E 149TH ST
BRONX NY
10455-1314
US

IV. Provider business mailing address

248 W 35TH ST
NEW YORK NY
10001-2505
US

V. Phone/Fax

Practice location:
  • Phone: 855-681-8700
  • Fax: 646-380-1322
Mailing address:
  • Phone: 718-681-8700
  • Fax: 646-380-1322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number079786
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: