=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124166145
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LINCOLN MEDICAL & MENTAL HEATH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 234 E 149TH ST
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10451-5504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-579-5156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 NEPTUNE BLVD APT 8R
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11561-4654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-431-4756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MENTAL HEATH COUNSELOR
-----------------------------------------------------
Name | MR. DAVID W. GOLDBERG
-----------------------------------------------------
Credential | MS. ED
-----------------------------------------------------
Telephone | 718-579-5156
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC2000X
-----------------------------------------------------
Taxonomy Name | Children's Hospital
-----------------------------------------------------
License Number | 000334
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------