Healthcare Provider Details

I. General information

NPI: 1730705757
Provider Name (Legal Business Name): EDWARD CHAN LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6729 MYRTLE AVE
GLENDALE NY
11385-7063
US

IV. Provider business mailing address

6729 MYRTLE AVE
GLENDALE NY
11385-7063
US

V. Phone/Fax

Practice location:
  • Phone: 718-456-7001
  • Fax:
Mailing address:
  • Phone: 184-567-0017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number103799
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: