Healthcare Provider Details

I. General information

NPI: 1932786761
Provider Name (Legal Business Name): ALEXANDR USOV LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 BRIELLE AVE BLDG H
STATEN ISLAND NY
10314-6427
US

IV. Provider business mailing address

388 COLON AVE
STATEN ISLAND NY
10308-1418
US

V. Phone/Fax

Practice location:
  • Phone: 718-412-3160
  • Fax:
Mailing address:
  • Phone: 347-867-2666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103148
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: