Provider Demographics
NPI:1245437177
Name:CONWAY, JEFFREY RAYMOND (LCSW)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:RAYMOND
Last Name:CONWAY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 W 42ND ST
Mailing Address - Street 2:35D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-6945
Mailing Address - Country:US
Mailing Address - Phone:917-499-8212
Mailing Address - Fax:
Practice Address - Street 1:875 6TH AVE
Practice Address - Street 2:1603
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3507
Practice Address - Country:US
Practice Address - Phone:212-481-2469
Practice Address - Fax:212-481-2460
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0727721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02690320Medicaid
NY02690320Medicaid