Healthcare Provider Details

I. General information

NPI: 1801609375
Provider Name (Legal Business Name): EVITA FAJIRATUR ROHMAH LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2025
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10818 QUEENS BLVD FL 5
FOREST HILLS NY
11375-4748
US

IV. Provider business mailing address

10818 QUEENS BLVD FL 5
FOREST HILLS NY
11375-4748
US

V. Phone/Fax

Practice location:
  • Phone: 212-804-7659
  • Fax:
Mailing address:
  • Phone: 212-804-7659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12634901
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: