Provider Demographics
NPI:1508227265
Name:VERNON, WALTER
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:VERNON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:WALTER
Other - Middle Name:HUDSON
Other - Last Name:VERNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:435 WEBSTER AVE APT 6PH
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801
Mailing Address - Country:US
Mailing Address - Phone:718-884-2992
Mailing Address - Fax:718-884-2901
Practice Address - Street 1:435 WEBSTER AVE APT 6PH
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801
Practice Address - Country:US
Practice Address - Phone:718-884-2992
Practice Address - Fax:718-884-2901
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYCPS-P388101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY131930700OtherRIVERDALE MENTAL HEALTH ASSOCIATION