Provider Demographics
NPI:1417314154
Name:MENTAL HEALTH PROVIDERS OF WESTERN QUEENS, INC.
Entity Type:Organization
Organization Name:MENTAL HEALTH PROVIDERS OF WESTERN QUEENS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:LAZO
Authorized Official - Last Name:MONTANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:718-898-5085
Mailing Address - Street 1:6207 WOODSIDE AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3576
Mailing Address - Country:US
Mailing Address - Phone:718-898-5085
Mailing Address - Fax:718-898-8852
Practice Address - Street 1:6207 WOODSIDE AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3576
Practice Address - Country:US
Practice Address - Phone:718-898-5085
Practice Address - Fax:718-898-8852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096826261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder