Healthcare Provider Details

I. General information

NPI: 1174079024
Provider Name (Legal Business Name): MR. LESLIE CHAMORRO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4419 3RD AVE SUITE 1A
BRONX NY
10457-2562
US

IV. Provider business mailing address

4419 3RD AVENUE GUIDANCE CENTER SUITE 1A
BRONX NY
10457
US

V. Phone/Fax

Practice location:
  • Phone: 718-364-7700
  • Fax: 718-364-1513
Mailing address:
  • Phone: 718-364-7700
  • Fax: 718-364-1513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number087891
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: