=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649828575
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN TALK LCSW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2019
-----------------------------------------------------
Last Update Date | 09/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 E 61ST ST STE 11S
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065-8183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-553-1870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 251 1ST ST PH 9C
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11215-1987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-553-1870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-FOUNDER
-----------------------------------------------------
Name | MARIEL MANGOLD
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 917-553-1870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------