Healthcare Provider Details

I. General information

NPI: 1043220171
Provider Name (Legal Business Name): MICHELLE RUBIN CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 RAVENHURST AVE
STATEN ISLAND NY
10310-2664
US

IV. Provider business mailing address

10 KATHY PL APT 2D
STATEN ISLAND NY
10314-5925
US

V. Phone/Fax

Practice location:
  • Phone: 718-983-8872
  • Fax: 718-983-0348
Mailing address:
  • Phone: 718-983-8872
  • Fax: 718-983-0348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0537031
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: