MEDICARE: MR. JOHN LYONS CASAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	170610001	NY

General Provider Information

NPI Number	:	1144692005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN LYONS CASAC

Provider Business Mailing Address
First Line	:	402 E 156TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-1232
Country	:	US
Telephone Number	:	718-993-2376
Fax Number	:	718-993-9164

Provider Business Practice Location Address
First Line	:	402 E 156TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-1232
Country	:	US
Telephone Number	:	718-993-2376
Fax Number	:	718-993-9164

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2015
Last Update Date	:	10/30/2015

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