Healthcare Provider Details

I. General information

NPI: 1972823714
Provider Name (Legal Business Name): CHEDVA LAX LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 08/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 BEACH 9TH ST SUITE C
FAR ROCKAWAY NY
11691-5636
US

IV. Provider business mailing address

156 BEACH 9TH ST SUITE C
FAR ROCKAWAY NY
11691-5636
US

V. Phone/Fax

Practice location:
  • Phone: 347-695-9700
  • Fax: 347-695-9701
Mailing address:
  • Phone: 347-695-9700
  • Fax: 347-695-9701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP80334
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: