Healthcare Provider Details

I. General information

NPI: 1659411510
Provider Name (Legal Business Name): ALBERT JOHN TREADWELL III LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14732 JAMAICA AVE
JAMAICA NY
11435-4042
US

IV. Provider business mailing address

2368 81ST ST
BROOKLYN NY
11214-2021
US

V. Phone/Fax

Practice location:
  • Phone: 718-526-8400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR058284
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: