Provider Demographics
NPI:1578095329
Name:CORDOVA, CHARLES (MHC-LP)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:CORDOVA
Suffix:
Gender:M
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 W 108TH ST
Mailing Address - Street 2:THE BRIDGE 5TH FL CLINIC
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-2956
Mailing Address - Country:US
Mailing Address - Phone:718-542-8080
Mailing Address - Fax:
Practice Address - Street 1:248 W 108TH ST
Practice Address - Street 2:THE BRIDGE 5TH FL CLINIC
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-2956
Practice Address - Country:US
Practice Address - Phone:718-542-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP03157101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health