Provider Demographics
NPI:1528583507
Name:MARY NG-TEDJASUKMANA, LCSW, PLLC
Entity Type:Organization
Organization Name:MARY NG-TEDJASUKMANA, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST/ LIFE COACH
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:NG-TEDJASUKMANA, LCSW, PLLC
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, CPLC, LCSW
Authorized Official - Phone:718-395-2064
Mailing Address - Street 1:1863 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-2549
Mailing Address - Country:US
Mailing Address - Phone:718-395-2064
Mailing Address - Fax:
Practice Address - Street 1:1863 W 8TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-2549
Practice Address - Country:US
Practice Address - Phone:718-395-2064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC057121001041C0700X
NY0814831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty