Provider Demographics
NPI:1104200294
Name:MENTAL HEALTH PROVIDERS OF WESTERN QUEENS
Entity type:Organization
Organization Name:MENTAL HEALTH PROVIDERS OF WESTERN QUEENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:LAING
Authorized Official - Last Name:AMBIA
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:917-566-3754
Mailing Address - Street 1:213 TAAFFE PL
Mailing Address - Street 2:APT. 214
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-4378
Mailing Address - Country:US
Mailing Address - Phone:917-566-3754
Mailing Address - Fax:
Practice Address - Street 1:3708 91ST ST
Practice Address - Street 2:SUITE 3A
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7928
Practice Address - Country:US
Practice Address - Phone:718-779-2263
Practice Address - Fax:718-779-2225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY094706251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY094706OtherLMSW LICENSE NUMBER