Provider Demographics
NPI:1134665565
Name:IN DEPTH PSYCHOTHERAPY LCSW PC
Entity Type:Organization
Organization Name:IN DEPTH PSYCHOTHERAPY LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GUADALUPE
Authorized Official - Middle Name:
Authorized Official - Last Name:AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:917-907-4737
Mailing Address - Street 1:3225 90TH ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11369-2356
Mailing Address - Country:US
Mailing Address - Phone:917-907-4737
Mailing Address - Fax:
Practice Address - Street 1:3225 90TH ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11369-2356
Practice Address - Country:US
Practice Address - Phone:917-907-4737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055836-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty