MEDICARE: MENTAL HEALTH PROVIDERS OF WESTERN QUEENS

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	251S00000X	Community/Behavioral Health Agency	094706	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	094706	OTHER	NY	LMSW LICENSE NUMBER

General Provider Information

NPI Number	:	1104200294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENTAL HEALTH PROVIDERS OF WESTERN QUEENS

Provider Business Mailing Address
First Line	:	213 TAAFFE PL
Second Line	:	APT. 214
City	:	BROOKLYN
State	:	NY
Zip	:	11205-4378
Country	:	US
Telephone Number	:	917-566-3754
Fax Number	:

Provider Business Practice Location Address
First Line	:	3708 91ST ST
Second Line	:	SUITE 3A
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-7928
Country	:	US
Telephone Number	:	718-779-2263
Fax Number	:	718-779-2225

Authorized Official
Title or Position	:	CLINICIAN
Name	:	KATHERINE LAING AMBIA
Credential	:	LMSW
Telephone Number	:	917-566-3754

Provider Enumeration Date	:	07/17/2015
Last Update Date	:	07/17/2015

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