Healthcare Provider Details

I. General information

NPI: 1427602846
Provider Name (Legal Business Name): MC QUEEN AND OTUYELU LCSW WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

941 FOREST AVENUE
STATEN ISLAND NY
10310
US

IV. Provider business mailing address

39 LOCKMAN AVENUE
STATEN ISLAND NY
10303
US

V. Phone/Fax

Practice location:
  • Phone: 347-410-2770
  • Fax: 718-273-4017
Mailing address:
  • Phone: 347-410-2770
  • Fax: 718-273-4017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: FONUSHO O OTUYELU
Title or Position: CO-PARTNER
Credential: LCSW
Phone: 347-410-2770