Provider Demographics
NPI:1285277871
Name:LO, CARMEN
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:LO
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 1:3722 80TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6825
Mailing Address - Country:US
Mailing Address - Phone:917-575-7692
Mailing Address - Fax:
Practice Address - Street 1:225 LAFAYETTE ST APT 4C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-4012
Practice Address - Country:US
Practice Address - Phone:833-775-6252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109991104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty