Healthcare Provider Details

I. General information

NPI: 1710139274
Provider Name (Legal Business Name): LUIS BRIGNOLO LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14101 68TH DR FL 1
FLUSHING NY
11367-1635
US

IV. Provider business mailing address

14101 68TH DR
FLUSHING NY
11367-1635
US

V. Phone/Fax

Practice location:
  • Phone: 718-551-1868
  • Fax:
Mailing address:
  • Phone: 718-551-1868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number008172
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number027228
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: