Provider Demographics
NPI:1518374552
Name:FUKUDA, MAYA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:MAYA
Middle Name:
Last Name:FUKUDA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-3270
Mailing Address - Country:US
Mailing Address - Phone:718-842-1412
Mailing Address - Fax:718-947-2257
Practice Address - Street 1:966 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-3270
Practice Address - Country:US
Practice Address - Phone:718-842-1412
Practice Address - Fax:718-947-2257
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY087588104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker