Healthcare Provider Details

I. General information

NPI: 1114071826
Provider Name (Legal Business Name): KURIAKO M CHACKO LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LINCOLN MEDICAL AND MENTAL HEALTH CENTER 234 E 149TH ST.
BRONX NY
10451
US

IV. Provider business mailing address

187 HUDSON TER
YONKERS NY
10701-1917
US

V. Phone/Fax

Practice location:
  • Phone: 718-579-5657
  • Fax: 718-579-5310
Mailing address:
  • Phone: 914-964-6639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0611821
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: