Healthcare Provider Details

I. General information

NPI: 1437326253
Provider Name (Legal Business Name): NELLIE E. LICIAGA LCSW, M-CASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELAINE LEDERER EXECUTIVE DIRECTOR

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 02/10/2026
Certification Date: 02/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9729 64TH RD
REGO PARK NY
11374-2259
US

IV. Provider business mailing address

520 E 142ND ST APT 4A
BRONX NY
10454-2156
US

V. Phone/Fax

Practice location:
  • Phone: 718-896-3400
  • Fax:
Mailing address:
  • Phone: 347-256-8205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12366
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: