Provider Demographics
NPI:1265776488
Name:EAGAN MIZRACHI, RENEE
Entity type:Individual
Prefix:MS
First Name:RENEE
Middle Name:
Last Name:EAGAN MIZRACHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:
Other - Last Name:EAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:57 W 84TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-4713
Mailing Address - Country:US
Mailing Address - Phone:917-410-0362
Mailing Address - Fax:
Practice Address - Street 1:750 TILDEN ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-6013
Practice Address - Country:US
Practice Address - Phone:917-410-0362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0754621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical