Healthcare Provider Details

I. General information

NPI: 1033766324
Provider Name (Legal Business Name): JONATHAN BLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WESTCHESTER SQ
BRONX NY
10461-3525
US

IV. Provider business mailing address

1594 E MEGAN ST
CHANDLER AZ
85225-9008
US

V. Phone/Fax

Practice location:
  • Phone: 718-931-4045
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW-19490
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: