Healthcare Provider Details

I. General information

NPI: 1487738761
Provider Name (Legal Business Name): TRI STATE COUNSELING AND MEDIATION LCSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 W 32ND ST STE 1511
NEW YORK NY
10001-3875
US

IV. Provider business mailing address

25403 84TH DR REGISTERED OFFICE
FLORAL PARK NY
11001-1009
US

V. Phone/Fax

Practice location:
  • Phone: 917-215-2169
  • Fax: 801-708-0844
Mailing address:
  • Phone: 646-523-2352
  • Fax: 801-708-0844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC01333400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number523650470
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR044004-01
License Number StateNY

VIII. Authorized Official

Name: MR. VASUDEVA CHIKKATUR MURTHY
Title or Position: PRESIDENT
Credential: L.C.S.W.
Phone: 646-523-2352