Provider Demographics
NPI:1922678242
Name:COCO BRAZOBAN, CARMEN DIRSSIS
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:DIRSSIS
Last Name:COCO BRAZOBAN
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 1:99 FEATHERBED LN APT 2C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-1610
Mailing Address - Country:US
Mailing Address - Phone:917-201-9244
Mailing Address - Fax:
Practice Address - Street 1:1727 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-4611
Practice Address - Country:US
Practice Address - Phone:212-694-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker