Provider Demographics
NPI:1427602846
Name:MC QUEEN AND OTUYELU LCSW WELLNESS
Entity Type:Organization
Organization Name:MC QUEEN AND OTUYELU LCSW WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:FONUSHO
Authorized Official - Middle Name:O
Authorized Official - Last Name:OTUYELU
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:347-410-2770
Mailing Address - Street 1:39 LOCKMAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303
Mailing Address - Country:US
Mailing Address - Phone:347-410-2770
Mailing Address - Fax:718-273-4017
Practice Address - Street 1:941 FOREST AVENUE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310
Practice Address - Country:US
Practice Address - Phone:347-410-2770
Practice Address - Fax:718-273-4017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty