Provider Demographics
NPI:1477699791
Name:MENTAL HEALTH PROVIDERS OF WESTERN QUEENS, INC.
Entity type:Organization
Organization Name:MENTAL HEALTH PROVIDERS OF WESTERN QUEENS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARTINEZ-CAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-672-1705
Mailing Address - Street 1:74 09 37TH AVE SUITE 315
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6303
Mailing Address - Country:US
Mailing Address - Phone:718-672-1705
Mailing Address - Fax:718-672-2027
Practice Address - Street 1:74 09 37TH AVE
Practice Address - Street 2:SUITE 315
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6303
Practice Address - Country:US
Practice Address - Phone:718-672-1705
Practice Address - Fax:718-672-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00848453Medicaid
NY00848453Medicaid