Healthcare Provider Details

I. General information

NPI: 1003034620
Provider Name (Legal Business Name): CHARLES CUCCHIARA M.DIV.,L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 E 11TH ST SUITE 312
NEW YORK NY
10003-6811
US

IV. Provider business mailing address

80 E 11TH ST SUITE 312
NEW YORK NY
10003-6811
US

V. Phone/Fax

Practice location:
  • Phone: 212-979-6445
  • Fax: 212-979-6445
Mailing address:
  • Phone: 212-979-6445
  • Fax: 212-979-6445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number071612
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: