Basic Information
| Provider Information | |||||||||
| NPI: | 1114004447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | NELSON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 DIRENZO CT | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103093623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182271031 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2795 RICHMOND AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103145857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187619800 | ||||||||
| FaxNumber: | 7183701142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 070210-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00070210 | 05 | NY | MEDICAID | 063752-A37 | 01 | NY | HEALTH FIRST | OTHER | W22701 | 01 | NY | MAGELLEN | OTHER |