Provider Demographics
NPI:1558683912
Name:MINAKAN, RIESA P (LMSW)
Entity type:Individual
Prefix:MS
First Name:RIESA
Middle Name:P
Last Name:MINAKAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:RIESA
Other - Middle Name:PROMOTE
Other - Last Name:MINAKAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:6 GRAMATAN AVE
Mailing Address - Street 2:C/O WJCS
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-3208
Mailing Address - Country:US
Mailing Address - Phone:914-668-8938
Mailing Address - Fax:914-668-2545
Practice Address - Street 1:6 GRAMATAN AVE
Practice Address - Street 2:C/O WJCS
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-3208
Practice Address - Country:US
Practice Address - Phone:914-668-8938
Practice Address - Fax:914-668-2545
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083778104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235918Medicaid