Healthcare Provider Details

I. General information

NPI: 1538481403
Provider Name (Legal Business Name): MIRTA I HABER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2010
Last Update Date: 02/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4404 QUEENS BLVD 2ND FLOOR
SUNNYSIDE NY
11104-2406
US

IV. Provider business mailing address

4404 QUEENS BLVD 2ND FLOOR
SUNNYSIDE NY
11104-2406
US

V. Phone/Fax

Practice location:
  • Phone: 718-706-1663
  • Fax: 718-706-0635
Mailing address:
  • Phone: 718-706-1663
  • Fax: 718-706-0635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number080712
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: