Provider Demographics
NPI:1629729595
Name:CANADA, GEOFFREY JR (LMSW)
Entity Type:Individual
Prefix:MR
First Name:GEOFFREY
Middle Name:
Last Name:CANADA
Suffix:JR
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4299
Mailing Address - Country:US
Mailing Address - Phone:516-655-1310
Mailing Address - Fax:
Practice Address - Street 1:65 HILTON AVE STE 300
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-2817
Practice Address - Country:US
Practice Address - Phone:516-798-4070
Practice Address - Fax:516-778-5795
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113647104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker