Provider Demographics
NPI:1437249455
Name:WARREN, JACQUELINE MARIA (LCSW, CASAC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:MARIA
Last Name:WARREN
Suffix:
Gender:F
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 TILLEY PL
Mailing Address - Street 2:
Mailing Address - City:SEA CLIFF
Mailing Address - State:NY
Mailing Address - Zip Code:11579-1019
Mailing Address - Country:US
Mailing Address - Phone:516-801-0703
Mailing Address - Fax:516-801-0703
Practice Address - Street 1:245 TILLEY PL
Practice Address - Street 2:
Practice Address - City:SEA CLIFF
Practice Address - State:NY
Practice Address - Zip Code:11579-1019
Practice Address - Country:US
Practice Address - Phone:516-801-0703
Practice Address - Fax:516-801-0703
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5263101YA0400X
NYR0535611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7483569OtherGHI PROVIDER NUMBER
NY031764OtherVALUE OPTIONS PROVIDER NO
NYN4X882Medicare ID - Type UnspecifiedEMPIRE GROUP