Healthcare Provider Details

I. General information

NPI: 1487615910
Provider Name (Legal Business Name): CAROL J DEACON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 GREENE ST SUITE 504
NEW YORK NY
10012-3813
US

IV. Provider business mailing address

192 SPRING ST APT. 5
NEW YORK NY
10012-5600
US

V. Phone/Fax

Practice location:
  • Phone: 212-966-5155
  • Fax:
Mailing address:
  • Phone: 212-226-4618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP064089-2
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: