Provider Demographics
NPI:1952540833
Name:IDEZ, PABLO (LCSW)
Entity type:Individual
Prefix:
First Name:PABLO
Middle Name:
Last Name:IDEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 DALTON LN
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-3909
Mailing Address - Country:US
Mailing Address - Phone:347-772-8373
Mailing Address - Fax:
Practice Address - Street 1:97 POWERHOUSE RD STE 104
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-2046
Practice Address - Country:US
Practice Address - Phone:347-772-8373
Practice Address - Fax:718-225-9201
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP063837-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical