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General NPI Number Information
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NPI Number | 1811755820
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Entity Type | Organization
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Legal Business Name | MSG
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Dates
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Enumeration Date | 03/13/2024
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Last Update Date | 03/13/2024
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Provider Practice Location Address
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Address Line | 2850 CLAFLIN AVE APT 602
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City | BRONX
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State | NY
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Zip | 10468-2228
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Country | US
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Telephone | 646-338-2133
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Fax |
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Provider Business Mailing Address
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Address Line | 234 EVERETT PL
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City | ENGLEWOOD
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State | NJ
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Zip | 07631-1660
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Country | US
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Telephone | 646-338-2133
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH THERAPIST
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Name | MICHAEL STEVEN GONZALEZ
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Credential | LCSW
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Telephone | 646-338-2133
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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