Healthcare Provider Details

I. General information

NPI: 1215388384
Provider Name (Legal Business Name): QUEENS COUNSELING FOR CHANGE, LCSW, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4461A 11TH ST
LONG ISLAND CITY NY
11101-5102
US

IV. Provider business mailing address

4461A 11TH ST
LONG ISLAND CITY NY
11101-5102
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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. LUCILLE BERBERICH
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 718-424-6191