Provider Demographics
NPI:1962844050
Name:QUEENS WTC HEALTH PROGRAM
Entity Type:Organization
Organization Name:QUEENS WTC HEALTH PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:SEGOVIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-267-2420
Mailing Address - Street 1:9777 QUEENS BLVD FL 9
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9777 QUEENS BLVD FL 9
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:718-267-2420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH SHORE LONG ISLAND JEWISH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY081917261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine