Healthcare Provider Details

I. General information

NPI: 1477150019
Provider Name (Legal Business Name): JESSE FARR-BAENZIGER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 41ST AVE
LONG ISLAND CITY NY
11101-4801
US

IV. Provider business mailing address

2101 41ST AVE
LONG ISLAND CITY NY
11101-4801
US

V. Phone/Fax

Practice location:
  • Phone: 718-361-6266
  • Fax:
Mailing address:
  • Phone: 718-361-6266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number117571
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberTEMP
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104061
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: