Provider Demographics
NPI:1770247363
Name:MAHFOUZ, BASSANT TALAAT
Entity type:Individual
Prefix:
First Name:BASSANT
Middle Name:TALAAT
Last Name:MAHFOUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1780 76TH ST APT D6
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-1162
Mailing Address - Country:US
Mailing Address - Phone:347-341-7309
Mailing Address - Fax:
Practice Address - Street 1:1780 76TH ST APT D6
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-1162
Practice Address - Country:US
Practice Address - Phone:347-341-7309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYZP10813EOtherHEALTHFIRST
NY81271108132Medicaid
NYZP10813EMedicaid