Healthcare Provider Details

I. General information

NPI: 1912028184
Provider Name (Legal Business Name): KATHLEEN VALLI MENTAL HEALTH COUNSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

QUEENS CENTERS FOR PROGRESS 81-15 164TH STREET
JAMAICA NY
11432
US

IV. Provider business mailing address

5810 69TH ST
MASPETH NY
11378-2523
US

V. Phone/Fax

Practice location:
  • Phone: 718-380-3000
  • Fax:
Mailing address:
  • Phone: 718-779-3116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number000291
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: