MEDICARE: TIM GIT SIMON LAM MHC-LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1023766805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIM GIT SIMON LAM MHC-LP

Provider Business Mailing Address
First Line	:	754 MACE AVE APT 2K
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10467-1083
Country	:	US
Telephone Number	:	347-282-3478
Fax Number	:

Provider Business Practice Location Address
First Line	:	2417 3RD AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10451-6331
Country	:	US
Telephone Number	:	800-421-2031
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2022
Last Update Date	:	03/11/2022

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