Healthcare Provider Details

I. General information

NPI: 1740100775
Provider Name (Legal Business Name): IDARESIT JAMES UDOFIA LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E GREENWICH AVE
ROOSEVELT NY
11575-1221
US

IV. Provider business mailing address

125 E GREENWICH AVE
ROOSEVELT NY
11575-1221
US

V. Phone/Fax

Practice location:
  • Phone: 917-727-5015
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number002811
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: