Healthcare Provider Details

I. General information

NPI: 1386957801
Provider Name (Legal Business Name): PD MENTAL HEALTH COUNSELING OF WESTERN QUEENS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7410 35TH AVE SUITE 107 W
JACKSON HEIGHTS NY
11372-8197
US

IV. Provider business mailing address

7410 35TH AVE SUITE 107 W
JACKSON HEIGHTS NY
11372-8197
US

V. Phone/Fax

Practice location:
  • Phone: 718-672-1538
  • Fax: 718-429-0713
Mailing address:
  • Phone: 718-672-1538
  • Fax: 718-429-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001402
License Number StateNY

VIII. Authorized Official

Name: MR. PATRICIO DESTVET
Title or Position: DIRECTOR
Credential: LMHC
Phone: 718-672-1538