Healthcare Provider Details

I. General information

NPI: 1750862967
Provider Name (Legal Business Name): UNION SQUARE PSYCHOTHERAPY, LCSW, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2018
Last Update Date: 12/12/2019
Certification Date: 12/12/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 E 12TH ST # MD-8
NEW YORK NY
10003-4632
US

IV. Provider business mailing address

44 E 12TH ST # MD-8
NEW YORK NY
10003-4632
US

V. Phone/Fax

Practice location:
  • Phone: 917-885-7892
  • Fax:
Mailing address:
  • Phone: 917-885-7892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number086846
License Number StateNY

VIII. Authorized Official

Name: MR. JOSH WOLF-POWERS
Title or Position: OWNER/MEMBER
Credential: MBA, LCSW
Phone: 917-885-7892