Provider Demographics
NPI:1518365220
Name:JOHN, NODEREA (LCSW)
Entity Type:Individual
Prefix:
First Name:NODEREA
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:884 E 54TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-1211
Mailing Address - Country:US
Mailing Address - Phone:347-742-5511
Mailing Address - Fax:
Practice Address - Street 1:2020 CONEY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223
Practice Address - Country:US
Practice Address - Phone:347-742-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-11
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY077784-1104100000X
NY0870071041C0700X
NY087007-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker