Provider Demographics
NPI:1811247042
Name:IRIZARRY, ALICIA (STUDENT INTERN)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:IRIZARRY
Suffix:
Gender:F
Credentials:STUDENT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16015 GRAND CENTRAL PKWY
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1130
Mailing Address - Country:US
Mailing Address - Phone:347-891-4041
Mailing Address - Fax:
Practice Address - Street 1:8956 162ND ST FL 2
Practice Address - Street 2:THE CHILD CENTER OF NEW YORK
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5072
Practice Address - Country:US
Practice Address - Phone:718-657-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093792-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY117334554Medicaid