Healthcare Provider Details

I. General information

NPI: 1568613917
Provider Name (Legal Business Name): EMILY MUDGE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2008
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 FLATBUSH AVE
BROOKLYN NY
11217-2812
US

IV. Provider business mailing address

100 8TH AVE APT 4E
BROOKLYN NY
11215-1532
US

V. Phone/Fax

Practice location:
  • Phone: 718-622-2000
  • Fax:
Mailing address:
  • Phone: 203-912-5159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number078960
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: