Healthcare Provider Details

I. General information

NPI: 1588696124
Provider Name (Legal Business Name): CAROL PAVIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 RICHMOND RD
STATEN ISLAND NY
10304-2304
US

IV. Provider business mailing address

100 COLFAX AVE
STATEN ISLAND NY
10306-3306
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-1416
  • Fax: 718-983-0348
Mailing address:
  • Phone: 718-987-8521
  • Fax: 718-983-0348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberR058729-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: