Healthcare Provider Details

I. General information

NPI: 1336505411
Provider Name (Legal Business Name): LIAM CUDMORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 W 129TH ST #28
NEW YORK NY
10027-2704
US

IV. Provider business mailing address

317 NOSTRAND AVE APT 4
BROOKLYN NY
11216-1225
US

V. Phone/Fax

Practice location:
  • Phone: 617-388-9391
  • Fax:
Mailing address:
  • Phone: 617-388-9391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number096359-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: