Provider Demographics
NPI:1114286101
Name:LCSW INTERVENTIONS FOR EMOTIONAL GROWTH, PC
Entity Type:Organization
Organization Name:LCSW INTERVENTIONS FOR EMOTIONAL GROWTH, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIGNOLO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:718-520-0798
Mailing Address - Street 1:14101 68TH DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:KEW GARDENS HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1635
Mailing Address - Country:US
Mailing Address - Phone:718-520-0798
Mailing Address - Fax:
Practice Address - Street 1:14101 68TH DR
Practice Address - Street 2:SUITE A
Practice Address - City:KEW GARDENS HILLS
Practice Address - State:NY
Practice Address - Zip Code:11367-1635
Practice Address - Country:US
Practice Address - Phone:718-520-0798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO462221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9865705OtherAETNA PIN
NY11699877OtherCAQH UNIVERSAL CREDENTIALS
NY274655OtherMHN PIN
NY02864693Medicaid
NY000600019133OtherHEALTH PLUS/ FAMILY HEALTH PLUS/ CHILD HEALTH PLUS
NY9865705OtherAETNA PIN