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General NPI Number Information
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NPI Number | 1811864093
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Entity Type | Organization
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Legal Business Name | BODEGA ROOTS THERAPY LCSW PLLC
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Dates
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Enumeration Date | 10/21/2025
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Last Update Date | 10/21/2025
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Provider Practice Location Address
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Address Line | 557 GRAND CONCOURSE STE 6017
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City | BRONX
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State | NY
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Zip | 10451-5253
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Country | US
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Telephone | 917-853-9364
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Fax |
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Provider Business Mailing Address
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Address Line | 557 GRAND CONCOURSE STE 6017
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City | BRONX
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State | NY
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Zip | 10451-5253
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Country | US
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Telephone | 917-853-9364
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | CARMEN SUSANA FAJARDO
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Credential | LCSW
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Telephone | 917-853-9364
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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 |
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License Number State |
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