Provider Demographics
NPI:1750769881
Name:PHILLIP MIRELL, LCSW
Entity type:Organization
Organization Name:PHILLIP MIRELL, LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:718-510-2029
Mailing Address - Street 1:1389 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-7521
Mailing Address - Country:US
Mailing Address - Phone:718-510-2029
Mailing Address - Fax:
Practice Address - Street 1:1389 E 18TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-7521
Practice Address - Country:US
Practice Address - Phone:718-510-2029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0778281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03344281Medicaid
NYA300048351Medicare UPIN