Provider Demographics
NPI:1215464631
Name:COMMUNITY COUNSELING AND MEDIATION
Entity type:Organization
Organization Name:COMMUNITY COUNSELING AND MEDIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY TANNEBERGER
Authorized Official - Middle Name:AGNES
Authorized Official - Last Name:TANNEBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:718-596-4991
Mailing Address - Street 1:115 W 31ST ST
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-3596
Mailing Address - Country:US
Mailing Address - Phone:212-564-6006
Mailing Address - Fax:212-564-3440
Practice Address - Street 1:115 W 31ST ST
Practice Address - Street 2:5TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3596
Practice Address - Country:US
Practice Address - Phone:212-564-6006
Practice Address - Fax:212-564-3440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-16
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR035238-1251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health