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General NPI Number Information
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NPI Number | 1578095329
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Entity Type | Individual
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Provider Name | CHARLES CORDOVA MHC-LP
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Gender | Male
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Dates
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Enumeration Date | 03/31/2017
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Last Update Date | 03/31/2017
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Provider Practice Location Address
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Address Line | 248 W 108TH ST THE BRIDGE 5TH FL CLINIC
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City | NEW YORK
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State | NY
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Zip | 10025-2956
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Country | US
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Telephone | 718-542-8080
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Fax |
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Provider Business Mailing Address
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Address Line | 248 W 108TH ST THE BRIDGE 5TH FL CLINIC
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City | NEW YORK
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State | NY
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Zip | 10025-2956
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Country | US
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Telephone | 718-542-8080
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | P03157
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License Number State | NY
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