Healthcare Provider Details

I. General information

NPI: 1992416226
Provider Name (Legal Business Name): BRIGITTE TIBANA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2022
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 30TH AVE FL 4
LONG ISLAND CITY NY
11102-2448
US

IV. Provider business mailing address

7810 34TH AVE APT 2B
JACKSON HEIGHTS NY
11372-2418
US

V. Phone/Fax

Practice location:
  • Phone: 718-808-7777
  • Fax:
Mailing address:
  • Phone: 347-894-6389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number104611-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number096309
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: