Healthcare Provider Details

I. General information

NPI: 1508465105
Provider Name (Legal Business Name): TRACY HAZAN BOUSQUET LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98120 QUEENS BLVD STE 1C
REGO PARK NY
11374-4414
US

IV. Provider business mailing address

65 N FULLERTON AVE APT 36
MONTCLAIR NJ
07042-3837
US

V. Phone/Fax

Practice location:
  • Phone: 718-830-0246
  • Fax:
Mailing address:
  • Phone: 917-741-5535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SL06560300
License Number StateNJ
# 6
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number094756
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: