Provider Demographics
NPI:1487738761
Name:TRI STATE COUNSELING AND MEDIATION LCSW PLLC
Entity type:Organization
Organization Name:TRI STATE COUNSELING AND MEDIATION LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VASUDEVA
Authorized Official - Middle Name:CHIKKATUR
Authorized Official - Last Name:MURTHY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:646-523-2352
Mailing Address - Street 1:25403 84TH DR
Mailing Address - Street 2:REGISTERED OFFICE
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-1009
Mailing Address - Country:US
Mailing Address - Phone:646-523-2352
Mailing Address - Fax:801-708-0844
Practice Address - Street 1:38 W 32ND ST STE 1511
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3875
Practice Address - Country:US
Practice Address - Phone:917-215-2169
Practice Address - Fax:801-708-0844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC013334001041C0700X
NY5236504701041S0200X
NYR044004-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16168101OtherAETNA
NY37199POtherHIP NEW YORK
NY579069OtherVALUE OPTIONS PROVIDER
0152427OtherGHI
NY02861356Medicaid
NY2324784OtherCIGNA BEHAVIORAL PROVIDER
NYR044004OtherMETROPLUS
NYR044004OtherMETROPLUS
NY02861356Medicaid
NY16168101OtherAETNA