Provider Demographics
NPI:1023609682
Name:TABBASSUM, IMTISAL
Entity type:Individual
Prefix:
First Name:IMTISAL
Middle Name:
Last Name:TABBASSUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IMTISAL
Other - Middle Name:
Other - Last Name:TABBASSUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:189 LYON ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-3101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:98120 QUEENS BLVD STE 1C
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4414
Practice Address - Country:US
Practice Address - Phone:718-830-0246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105488104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY105488OtherLMSW