Healthcare Provider Details

I. General information

NPI: 1780838060
Provider Name (Legal Business Name): PLAYDATE LMSW SOCIAL WORK PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2008
Last Update Date: 11/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 W 119TH ST SUITE 3R
NEW YORK NY
10026-1209
US

IV. Provider business mailing address

208 W 119TH ST SUITE 3R
NEW YORK NY
10026-1209
US

V. Phone/Fax

Practice location:
  • Phone: 917-863-3780
  • Fax: 646-596-7791
Mailing address:
  • Phone: 917-863-3780
  • Fax: 646-596-7791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number061668-1
License Number StateNY

VIII. Authorized Official

Name: MS. OLIVIA J NELSON
Title or Position: SOLE MBR
Credential: LMSW
Phone: 917-863-3780