Healthcare Provider Details

I. General information

NPI: 1891417077
Provider Name (Legal Business Name): ALYSSA TATYANA COLON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 CHICAGO AVE
STATEN ISLAND NY
10305-3757
US

IV. Provider business mailing address

250 MAPLE PKWY
STATEN ISLAND NY
10303-2460
US

V. Phone/Fax

Practice location:
  • Phone: 718-442-7828
  • Fax:
Mailing address:
  • Phone: 718-344-6643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number117400
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: