Provider Demographics
NPI:1518230911
Name:HEREDIA, LOURDES LIZ
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:LIZ
Last Name:HEREDIA
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 1:1268 MYRTLE AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-3210
Mailing Address - Country:US
Mailing Address - Phone:516-508-2588
Mailing Address - Fax:
Practice Address - Street 1:328 E 62ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-8206
Practice Address - Country:US
Practice Address - Phone:212-752-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY817690816171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator