Healthcare Provider Details

I. General information

NPI: 1265012876
Provider Name (Legal Business Name): LOIS MIRKOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9777 QUEENS BLVD
REGO PARK NY
11374-3335
US

IV. Provider business mailing address

9777 QUEENS BLVD
REGO PARK NY
11374-3335
US

V. Phone/Fax

Practice location:
  • Phone: 718-423-6200
  • Fax:
Mailing address:
  • Phone: 718-423-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number093433
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: