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General NPI Number Information
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NPI Number | 1669951596
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Entity Type | Organization
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Legal Business Name | OMNI PSYCHOTHERAPY, LCSW, P.C.
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Dates
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Enumeration Date | 08/10/2018
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Last Update Date | 07/11/2019
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Provider Practice Location Address
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Address Line | 180 S BROADWAY STE 405
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City | WHITE PLAINS
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State | NY
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Zip | 10605-1820
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Country | US
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Telephone | 917-805-0044
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Fax | 718-684-4896
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Provider Business Mailing Address
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Address Line | 180 S BROADWAY STE 405
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City | WHITE PLAINS
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State | NY
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Zip | 10605-1820
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Country | US
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Telephone | 917-805-0044
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Fax | 718-684-4896
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Authorized Official
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Title or Position | PRESIDENT
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Name | IVAN DILLER
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Credential | LCSW-R
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Telephone | 917-805-0044
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | R978093
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License Number State | NY
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