Healthcare Provider Details

I. General information

NPI: 1598094880
Provider Name (Legal Business Name): HEATH IAN BLOCH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2009
Last Update Date: 12/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24302 NORTHERN BLVD
DOUGLASTON NY
11362-1150
US

IV. Provider business mailing address

526 E 20TH ST APT 8G
NEW YORK NY
10009-1312
US

V. Phone/Fax

Practice location:
  • Phone: 718-423-6200
  • Fax: 718-423-9762
Mailing address:
  • Phone: 917-842-8629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number072020
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: