Provider Demographics
NPI:1720592504
Name:ADAMS, CHARISSE
Entity Type:Individual
Prefix:
First Name:CHARISSE
Middle Name:
Last Name:ADAMS
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 1:297 LEGION ST # 2A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-4042
Mailing Address - Country:US
Mailing Address - Phone:646-275-0044
Mailing Address - Fax:
Practice Address - Street 1:9777 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3335
Practice Address - Country:US
Practice Address - Phone:718-760-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108050-011041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY108050-01OtherLMSW