Basic Information
Provider Information | |||||||||
NPI: | 1770754418 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENRIQUEZ-PONS | ||||||||
FirstName: | LOIDA | ||||||||
MiddleName: | EUNICE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 541 CENTRAL AVE | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112071201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3473244170 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2795 RICHMOND AVE | ||||||||
Address2: |   | ||||||||
City: | STATEN ISLAND | ||||||||
State: | NY | ||||||||
PostalCode: | 103145857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7187619800 | ||||||||
FaxNumber: | 7183701142 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2008 | ||||||||
LastUpdateDate: | 03/21/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | P61850 | NY | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | P61850 | 01 | NY | PROFESSIONAL LICENSE # | OTHER |