Provider Demographics
NPI:1174764104
Name:ZURITA, OMAR JESUS (LCSW)
Entity type:Individual
Prefix:MR
First Name:OMAR
Middle Name:JESUS
Last Name:ZURITA
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 1:11835 QUEENS BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7211
Mailing Address - Country:US
Mailing Address - Phone:917-415-8764
Mailing Address - Fax:877-556-0666
Practice Address - Street 1:11835 QUEENS BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7200
Practice Address - Country:US
Practice Address - Phone:917-415-8764
Practice Address - Fax:718-425-4251
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-21
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0815301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03243074Medicaid