Provider Demographics
NPI:1750312070
Name:CLOUGH, QUINTIN JOHN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:QUINTIN
Middle Name:JOHN
Last Name:CLOUGH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 E 11TH ST
Mailing Address - Street 2:STE 423
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-6811
Mailing Address - Country:US
Mailing Address - Phone:917-579-8742
Mailing Address - Fax:
Practice Address - Street 1:80 E 11TH ST
Practice Address - Street 2:STE 423
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-6811
Practice Address - Country:US
Practice Address - Phone:917-579-8742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073577-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN2J841Medicare PIN