Provider Demographics
NPI:1619226966
Name:PARK AVE PSYCHOTHERAPY
Entity Type:Organization
Organization Name:PARK AVE PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:RHONDA
Authorized Official - Last Name:GITTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-634-0253
Mailing Address - Street 1:167 BEACH 135TH ST.
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-1303
Mailing Address - Country:US
Mailing Address - Phone:718-634-0253
Mailing Address - Fax:718-634-1056
Practice Address - Street 1:167 BEACH 135TH ST.
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-1303
Practice Address - Country:US
Practice Address - Phone:718-634-0253
Practice Address - Fax:718-634-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR027402103TC2200X, 104100000X, 1041C0700X, 2084P0804X
NY05000472225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance TherapistGroup - Multi-Specialty