Provider Demographics
NPI:1659666105
Name:ZWICK, AUDREY
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:ZWICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 JAVA ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11222-5424
Mailing Address - Country:US
Mailing Address - Phone:917-322-9485
Mailing Address - Fax:
Practice Address - Street 1:252 JAVA ST
Practice Address - Street 2:SUITE 110
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-5424
Practice Address - Country:US
Practice Address - Phone:917-322-9485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY084055104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1285628552OtherAGENCY NPI
NYWVE061OtherAGENCY MEDICARE