Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
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 TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number116462
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: