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General NPI Number Information
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NPI Number | 1508465105
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Entity Type | Individual
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Provider Name | TRACY HAZAN BOUSQUET LMSW
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Gender | Female
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Dates
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Enumeration Date | 10/23/2020
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Last Update Date | 10/29/2020
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Provider Practice Location Address
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Address Line | 98120 QUEENS BLVD STE 1C
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City | REGO PARK
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State | NY
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Zip | 11374-4414
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Country | US
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Telephone | 718-830-0246
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Fax |
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Provider Business Mailing Address
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Address Line | 65 N FULLERTON AVE APT 36
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City | MONTCLAIR
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State | NJ
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Zip | 07042-3837
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Country | US
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Telephone | 917-741-5535
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | 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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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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 | 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 #4
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 44SL06560300
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License Number State | NJ
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Taxonomy #6
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 094756
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License Number State | NY
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