Provider Demographics
NPI:1790802783
Name:FEDIRKO-GONZALEZ, NINA ELENA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:NINA
Middle Name:ELENA
Last Name:FEDIRKO-GONZALEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-1827
Mailing Address - Country:US
Mailing Address - Phone:516-742-1182
Mailing Address - Fax:516-742-1182
Practice Address - Street 1:626 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-1149
Practice Address - Country:US
Practice Address - Phone:516-742-1182
Practice Address - Fax:516-742-1182
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR026152-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN48X81Medicare ID - Type UnspecifiedPSYCHOTHERAPIST