Provider Demographics
NPI:1013256445
Name:CHAN, ERIN ROSE (LMSW)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:ROSE
Last Name:CHAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8268 164TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1121
Mailing Address - Country:US
Mailing Address - Phone:646-526-9611
Mailing Address - Fax:
Practice Address - Street 1:14310 SPRINGFIELD BLVD
Practice Address - Street 2:RM 107A
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-3240
Practice Address - Country:US
Practice Address - Phone:718-341-1914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086494104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03935504Medicaid