Provider Demographics
NPI:1013505783
Name:MINETTE LCSW PSYCHOTHERAPY SERVICES, PLLC
Entity Type:Organization
Organization Name:MINETTE LCSW PSYCHOTHERAPY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSE CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVERAS-GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:201-724-5489
Mailing Address - Street 1:140 W 52ND ST
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3120
Mailing Address - Country:US
Mailing Address - Phone:201-724-5489
Mailing Address - Fax:
Practice Address - Street 1:2960 GRAND CONCOURSE APT 3C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-1905
Practice Address - Country:US
Practice Address - Phone:201-724-5489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)