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General NPI Number Information
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NPI Number | 1790185395
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Entity Type | Organization
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Legal Business Name | SUPPORT EVALUATION AND INTERVENTION SERVICES LCSW P.C
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Dates
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Enumeration Date | 09/02/2014
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Last Update Date | 03/10/2017
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Provider Practice Location Address
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Address Line | 4035 JUNCTION BLVD
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City | CORONA
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State | NY
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Zip | 11368-2121
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Country | US
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Telephone | 917-995-3773
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Fax | 212-656-1412
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Provider Business Mailing Address
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Address Line | 4035 JUNCTION BLVD
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City | CORONA
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State | NY
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Zip | 11368-2121
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Country | US
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Telephone | 917-995-3773
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Fax | 212-656-1412
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Authorized Official
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Title or Position | PRESIDENT
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Name | KARINA PENA-TOLEDO
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Credential | LCSW
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Telephone | 917-995-3773
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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 | 080647-1
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License Number State | NY
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