=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073989570
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA MARIA LUCIANO LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2015
-----------------------------------------------------
Last Update Date | 08/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5676 RIVERDALE AVE SUITE 202 RIVERDALE MENTAL HEALTH ASSOCIATION
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-796-5300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 WADSWORTH AVE APT 1C
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10040-4171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-796-5300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical
-----------------------------------------------------
License Number | 095503-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------