MEDICARE: QUEEN-DESTINY MANSON CRPA

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1770150518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QUEEN-DESTINY MANSON CRPA

Provider Business Mailing Address
First Line	:	2761 SAMPSON AVE APT 3C
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10465-2935
Country	:	US
Telephone Number	:	347-928-1314
Fax Number	:

Provider Business Practice Location Address
First Line	:	2761 SAMPSON AVE APT 3C
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10465-2935
Country	:	US
Telephone Number	:	347-928-1314
Fax Number	:

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

Provider Enumeration Date	:	06/09/2021
Last Update Date	:	06/09/2021

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