Healthcare Provider Details

I. General information

NPI: 1184267197
Provider Name (Legal Business Name): TALI LAX LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 BROADWAY FL 34
NEW YORK NY
10007-3001
US

IV. Provider business mailing address

105 DUANE ST
NEW YORK NY
10007-3601
US

V. Phone/Fax

Practice location:
  • Phone: 347-391-4250
  • Fax:
Mailing address:
  • Phone: 646-789-3325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0727949
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: