Healthcare Provider Details

I. General information

NPI: 1598453862
Provider Name (Legal Business Name): RICKY LUONG PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2892 OCEAN AVE # 1024
BROOKLYN NY
11235-3106
US

IV. Provider business mailing address

2892 OCEAN AVE # 1024
BROOKLYN NY
11235-3106
US

V. Phone/Fax

Practice location:
  • Phone: 315-522-6641
  • Fax: 315-620-7664
Mailing address:
  • Phone: 315-522-6641
  • Fax: 315-620-7664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number404735
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: