Provider Demographics
NPI:1972640431
Name:VICUNA, CARLOS (LCSW)
Entity type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:
Last Name:VICUNA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 GREENPOINT AVE
Mailing Address - Street 2:APT. 7V
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-4532
Mailing Address - Country:US
Mailing Address - Phone:718-937-5852
Mailing Address - Fax:718-657-7137
Practice Address - Street 1:8956 162ND ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5072
Practice Address - Country:US
Practice Address - Phone:718-657-7100
Practice Address - Fax:718-657-7137
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0587011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical