Provider Demographics
NPI:1275314023
Name:BASSAL, MICOL (LMSW)
Entity Type:Individual
Prefix:
First Name:MICOL
Middle Name:
Last Name:BASSAL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 IPSWICH AVE APT 220
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-3261
Mailing Address - Country:US
Mailing Address - Phone:516-423-6447
Mailing Address - Fax:
Practice Address - Street 1:353 LEXINGTON AVE STE 506
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-0941
Practice Address - Country:US
Practice Address - Phone:646-494-2653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121009-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker