Provider Demographics
NPI:1821213497
Name:ADVANCE CENTER FOR PSYCHOTHERAPY
Entity Type:Organization
Organization Name:ADVANCE CENTER FOR PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:718-658-1123
Mailing Address - Street 1:115-23 180TH STREET
Mailing Address - Street 2:
Mailing Address - City:ST ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11434
Mailing Address - Country:US
Mailing Address - Phone:718-523-2527
Mailing Address - Fax:
Practice Address - Street 1:178-10 WEXFORD TERRACE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:718-658-1123
Practice Address - Fax:718-658-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR00986 1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3544 WXMedicare ID - Type Unspecified