=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598073553
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARITZA CARDONA-CAMPBELL LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2010
-----------------------------------------------------
Last Update Date | 07/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 513 W 166TH ST FL 4
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 121-292-8830
-----------------------------------------------------
Fax | 212-292-8839
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 513 W 166TH ST FL 4
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10032-4207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 121-292-8830
-----------------------------------------------------
Fax | 212-292-8839
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R044727-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------