Healthcare Provider Details

I. General information

NPI: 1588806293
Provider Name (Legal Business Name): ROY KENNETH YEAGER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2009
Last Update Date: 04/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 E 77TH ST FIRST FLOOR
NEW YORK NY
10075-1852
US

IV. Provider business mailing address

956 5TH AVE
NEW YORK NY
10075-1746
US

V. Phone/Fax

Practice location:
  • Phone: 212-288-8945
  • Fax: 212-288-5445
Mailing address:
  • Phone: 212-288-8945
  • Fax: 212-288-5445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number076402-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: