Provider Demographics
NPI:1083954077
Name:AVANTGARDE BEHAVIORAL HEALTH SERVICES LCSW PLLC
Entity Type:Organization
Organization Name:AVANTGARDE BEHAVIORAL HEALTH SERVICES LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUDMILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBINOV
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:917-291-2191
Mailing Address - Street 1:145 HASTINGS ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3017
Mailing Address - Country:US
Mailing Address - Phone:917-291-2191
Mailing Address - Fax:718-332-2273
Practice Address - Street 1:19 W 34TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3006
Practice Address - Country:US
Practice Address - Phone:917-291-2191
Practice Address - Fax:718-332-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0771511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400042543OtherMEDICARE
NY00077151Medicaid
1487737169OtherNPI