Healthcare Provider Details

I. General information

NPI: 1699406785
Provider Name (Legal Business Name): MATTHEW WILLNER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3046 NORTHERN BLVD
LONG ISLAND CITY NY
11101-2816
US

IV. Provider business mailing address

3046 NORTHERN BLVD
LONG ISLAND CITY NY
11101-2816
US

V. Phone/Fax

Practice location:
  • Phone: 718-424-6191
  • Fax:
Mailing address:
  • Phone: 718-424-6191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09933219
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number102742
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06674300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: