Healthcare Provider Details

I. General information

NPI: 1982251831
Provider Name (Legal Business Name): LILY BREFO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 07/11/2022
Certification Date: 07/11/2022
Deactivation Date: 07/20/2020
Reactivation Date: 06/22/2022

III. Provider practice location address

9114 37TH AVE
JACKSON HEIGHTS NY
11372-7920
US

IV. Provider business mailing address

9114 37TH AVE
JACKSON HEIGHTS NY
11372-7920
US

V. Phone/Fax

Practice location:
  • Phone: 718-779-1600
  • Fax:
Mailing address:
  • Phone: 718-779-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number24739
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number104811
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: