MEDICARE: QUEENS 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1407401011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUEENS PSYCHOTHERAPY LCSW PC

Provider Business Mailing Address
First Line	:	8786 188TH ST FL 1
Second Line	:
City	:	JAMAICA
State	:	NY
Zip	:	11423-1131
Country	:	US
Telephone Number	:	917-267-8359
Fax Number	:

Provider Business Practice Location Address
First Line	:	8786 188TH ST FL 1
Second Line	:
City	:	JAMAICA
State	:	NY
Zip	:	11423-1131
Country	:	US
Telephone Number	:	917-267-8359
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MATTHEW THOMAS DINER
Credential	:	PHD, LCSW
Telephone Number	:	917-267-8359

Provider Enumeration Date	:	08/09/2019
Last Update Date	:	08/09/2019

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