Provider Demographics
NPI:1629329438
Name:CLINICAL, CONSULTATION AND SUPERVISION SERVICES LCSW PLLC
Entity Type:Organization
Organization Name:CLINICAL, CONSULTATION AND SUPERVISION SERVICES LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:NERESTAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:917-653-8972
Mailing Address - Street 1:319 TONETTA LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-4134
Mailing Address - Country:US
Mailing Address - Phone:845-893-4948
Mailing Address - Fax:888-812-4062
Practice Address - Street 1:3510 BAINBRIDGE AVE APT S1
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-1419
Practice Address - Country:US
Practice Address - Phone:917-653-8972
Practice Address - Fax:888-812-4062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0631791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR063179OtherNYS LICENSE
NYN57452371Medicare PIN