MEDICARE: MR. CLEVELAND SHELTON JOSEPH 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	261QM0850X	Adult Mental Health Clinic/Center	101777	NY

General Provider Information

NPI Number	:	1528232220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLEVELAND SHELTON JOSEPH CASAC

Provider Business Mailing Address
First Line	:	4360 FURMAN AVE APT 4H
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10466-1544
Country	:	US
Telephone Number	:	347-346-9278
Fax Number	:	347-346-9278

Provider Business Practice Location Address
First Line	:	4360 FURMAN AVE APT 4H
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10466-1544
Country	:	US
Telephone Number	:	347-346-9278
Fax Number	:	347-346-9278

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

Provider Enumeration Date	:	04/15/2008
Last Update Date	:	04/15/2008

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