MEDICARE: TRI STATE COUNSELING AND MEDIATION LCSW PLLC

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	44SC01333400	NJ
2	1041S0200X	School Social Worker	523650470	NY
3	1041C0700X	Clinical Social Worker	R044004-01	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	16168101	OTHER	NY	AETNA
2	37199P	OTHER	NY	HIP NEW YORK
3	579069	OTHER	NY	VALUE OPTIONS PROVIDER
4	0152427	OTHER		GHI
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	2324784	OTHER	NY	CIGNA BEHAVIORAL PROVIDER
7	R044004	OTHER	NY	METROPLUS

General Provider Information

NPI Number	:	1487738761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI STATE COUNSELING AND MEDIATION LCSW PLLC

Provider Business Mailing Address
First Line	:	25403 84TH DR
Second Line	:	REGISTERED OFFICE
City	:	FLORAL PARK
State	:	NY
Zip	:	11001-1009
Country	:	US
Telephone Number	:	646-523-2352
Fax Number	:	801-708-0844

Provider Business Practice Location Address
First Line	:	38 W 32ND ST STE 1511
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10001-3875
Country	:	US
Telephone Number	:	917-215-2169
Fax Number	:	801-708-0844

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. VASUDEVA CHIKKATUR MURTHY
Credential	:	L.C.S.W.
Telephone Number	:	646-523-2352

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	06/11/2020

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