Provider Demographics
NPI:1316611452
Name:TIRADO-MANSILLA, PAULA GAVIOTA (LMSW)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:GAVIOTA
Last Name:TIRADO-MANSILLA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 PROSPECT ST APT I
Mailing Address - Street 2:
Mailing Address - City:GARFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07026-2545
Mailing Address - Country:US
Mailing Address - Phone:862-249-8568
Mailing Address - Fax:
Practice Address - Street 1:62-07 WOODSIDE AVENUE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377
Practice Address - Country:US
Practice Address - Phone:718-476-0074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113307104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker