Provider Demographics
NPI:1063013191
Name:CLINICIANS OF THE DIASPORA, LLC
Entity Type:Organization
Organization Name:CLINICIANS OF THE DIASPORA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:347-509-4648
Mailing Address - Street 1:232 WEST 116TH STREET
Mailing Address - Street 2:P.O. BOX 1073
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026
Mailing Address - Country:US
Mailing Address - Phone:347-509-4648
Mailing Address - Fax:
Practice Address - Street 1:203 W 117TH ST APT 3E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-2139
Practice Address - Country:US
Practice Address - Phone:347-509-4648
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health