MEDICARE: LIVED EXPERIENCE THERAPISTS, 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

General Provider Information

NPI Number	:	1902763915
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVED EXPERIENCE THERAPISTS, LCSW PLLC

Provider Business Mailing Address
First Line	:	97-11 SPRINGFIELD BLVD
Second Line	:
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11429
Country	:	US
Telephone Number	:	718-749-2596
Fax Number	:

Provider Business Practice Location Address
First Line	:	9711 SPRINGFIELD BLVD
Second Line	:
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11429-1328
Country	:	US
Telephone Number	:	718-749-2596
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	DR. JOSEPH DEVAUGHN WILLIAMS
Credential	:	DSW, LCSW
Telephone Number	:	718-749-2596

Provider Enumeration Date	:	01/09/2026
Last Update Date	:	01/09/2026

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