=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639717416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED MOMENT PSYCHOTHERAPY, LCSW, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2019
-----------------------------------------------------
Last Update Date | 12/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 CENTRAL PARK W APT 1C
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10025-8842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-755-9570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 CENTRAL PARK W APT 1C
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10025-8842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-755-9570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | DAN LIU
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 917-755-9570
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------