=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912506726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BY REPOSE LCSW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2020
-----------------------------------------------------
Last Update Date | 05/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 276 5TH AVE RM 704
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10001-4527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-920-1976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46 GUION ST
-----------------------------------------------------
City | PLEASANTVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10570-2106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-483-5627
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | MS. MARY MORGAN BREEN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 212-920-1976
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------