MEDICARE: IN DEPTH PSYCHOTHERAPY LCSW PC

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	1041C0700X	Clinical Social Worker	055836-1	NY

General Provider Information

NPI Number	:	1134665565
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IN DEPTH PSYCHOTHERAPY LCSW PC

Provider Business Mailing Address
First Line	:	3225 90TH ST
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11369-2356
Country	:	US
Telephone Number	:	917-907-4737
Fax Number	:

Provider Business Practice Location Address
First Line	:	3225 90TH ST
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11369-2356
Country	:	US
Telephone Number	:	917-907-4737
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GUADALUPE AVILA
Credential	:	LCSW
Telephone Number	:	917-907-4737

Provider Enumeration Date	:	01/09/2017
Last Update Date	:	03/24/2026

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