Provider Demographics
NPI:1720126063
Name:EDELSON, DEBORAH (LCSW)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:EDELSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 5TH AVE
Mailing Address - Street 2:SUITE 24
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3597
Mailing Address - Country:US
Mailing Address - Phone:718-857-8150
Mailing Address - Fax:347-413-5371
Practice Address - Street 1:645 SAINT JOHNS PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-4112
Practice Address - Country:US
Practice Address - Phone:718-270-2036
Practice Address - Fax:718-270-3910
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR050912-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN11J62Medicare ID - Type Unspecified