=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316734502
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUDREY LAROSA HENRY LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2025
-----------------------------------------------------
Last Update Date | 04/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 799 E GUN HILL RD FL 1
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10467-6107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-471-0200
-----------------------------------------------------
Fax | 929-535-7576
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4323 COLDEN ST APT 10A
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11355-5913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-606-6558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 086613
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------