Provider Demographics
NPI:1508529298
Name:PAGAN, RENITA NICOLE
Entity Type:Individual
Prefix:
First Name:RENITA
Middle Name:NICOLE
Last Name:PAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E 161ST ST APT 5B
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-6951
Mailing Address - Country:US
Mailing Address - Phone:914-320-0622
Mailing Address - Fax:
Practice Address - Street 1:860 MELROSE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5757
Practice Address - Country:US
Practice Address - Phone:917-473-6996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114199104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker