Healthcare Provider Details

I. General information

NPI: 1033418983
Provider Name (Legal Business Name): LUIS R FAGUNDES LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2011
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 1ST AVE
NEW YORK NY
10016-9196
US

IV. Provider business mailing address

248 W 108TH ST
NEW YORK NY
10025-2956
US

V. Phone/Fax

Practice location:
  • Phone: 212-562-4679
  • Fax:
Mailing address:
  • Phone: 212-562-4679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number078325
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: