Healthcare Provider Details

I. General information

NPI: 1770284176
Provider Name (Legal Business Name): THOMAS VIEIRA CARDOSO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 ROUTE 112
CORAM NY
11727-4116
US

IV. Provider business mailing address

14202 20TH AVE FL 3
FLUSHING NY
11351-3000
US

V. Phone/Fax

Practice location:
  • Phone: 631-920-8520
  • Fax:
Mailing address:
  • Phone: 917-563-3350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: