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NPI Code Detail

MEDICARE: SUPPORT EVALUATION AND INTERVENTION SERVICES LCSW P.C

MEDICARE: SUPPORT EVALUATION AND INTERVENTION SERVICES LCSW P.C
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
11041C0700XClinical Social Worker080647-1NY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11578717575OTHERNYNPI

General Provider Information

NPI Number : 1790185395
Entity Type Code : Organization
Provider Name (Legal Business Name) : SUPPORT EVALUATION AND INTERVENTION SERVICES LCSW P.C
Provider Business Mailing Address
First Line : 4035 JUNCTION BLVD
Second Line :
City : CORONA
State : NY
Zip : 11368-2121
Country : US
Telephone Number : 917-995-3773
Fax Number : 212-656-1412
Provider Business Practice Location Address
First Line : 4035 JUNCTION BLVD
Second Line :
City : CORONA
State : NY
Zip : 11368-2121
Country : US
Telephone Number : 917-995-3773
Fax Number : 212-656-1412
Authorized Official
Title or Position : PRESIDENT
Name : KARINA PENA-TOLEDO
Credential : LCSW
Telephone Number : 917-995-3773
Provider Enumeration Date : 09/02/2014
Last Update Date : 03/10/2017

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1134639602 — MS. MARILYN MALDONADO LMSW
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Directions to “SUPPORT EVALUATION AND INTERVENTION SERVICES LCSW P.C ” Practice Location

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