Healthcare Provider Details

I. General information

NPI: 1376279984
Provider Name (Legal Business Name): TINA LIU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MONTGOMERY ST
NEW YORK NY
10002-4808
US

IV. Provider business mailing address

248 W 105TH ST APT 5A
NEW YORK NY
10025-3932
US

V. Phone/Fax

Practice location:
  • Phone: 212-233-5032
  • Fax:
Mailing address:
  • Phone: 609-703-3608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: