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General NPI Number Information
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NPI Number | 1063013191
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Entity Type | Organization
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Legal Business Name | CLINICIANS OF THE DIASPORA, LLC
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Dates
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Enumeration Date | 11/04/2020
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Last Update Date | 11/04/2020
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Provider Practice Location Address
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Address Line | 203 W 117TH ST APT 3E
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City | NEW YORK
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State | NY
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Zip | 10026-2139
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Country | US
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Telephone | 347-509-4648
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Fax |
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Provider Business Mailing Address
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Address Line | 232 WEST 116TH STREET P.O. BOX 1073
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City | NEW YORK
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State | NY
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Zip | 10026
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Country | US
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Telephone | 347-509-4648
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Fax |
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Authorized Official
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Title or Position | C.E.O.
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Name | MS. MONICA THOMPSON
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Credential | LCSW
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Telephone | 347-509-4648
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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