Healthcare Provider Details

I. General information

NPI: 1760734701
Provider Name (Legal Business Name): TINA SOUVERAIN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10819 ROCKAWAY BLVD
SOUTH OZONE PARK NY
11420-1034
US

IV. Provider business mailing address

10819 ROCKAWAY BLVD
SOUTH OZONE PARK NY
11420-1034
US

V. Phone/Fax

Practice location:
  • Phone: 718-845-2620
  • Fax: 718-845-9380
Mailing address:
  • Phone: 718-845-2620
  • Fax: 718-845-9380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number086999
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: