Healthcare Provider Details

I. General information

NPI: 1326102575
Provider Name (Legal Business Name): SERGIO ROMAN URENO PH. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 08/13/2021
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 49TH ST LUTHERAN FHC SUNSET TERRACE
BROOKLYN NY
11220-2010
US

IV. Provider business mailing address

5800 3RD AVE MANAGED CARE DEPARTMENT
BROOKLYN NY
11220-3702
US

V. Phone/Fax

Practice location:
  • Phone: 718-854-1851
  • Fax: 718-435-8510
Mailing address:
  • Phone: 718-630-7477
  • Fax: 718-630-7437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number016031
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: