Healthcare Provider Details

I. General information

NPI: 1013508605
Provider Name (Legal Business Name): HAKI YETU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 S 12TH ST FL 3
NEWARK NJ
07103-1740
US

IV. Provider business mailing address

21 DOTY AVE
STATEN ISLAND NY
10305-4717
US

V. Phone/Fax

Practice location:
  • Phone: 646-500-4600
  • Fax:
Mailing address:
  • Phone: 646-500-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: BARBARA VICTOME
Title or Position: EXECUTIVE DIRECTOR
Credential: MSW, ACSW
Phone: 646-500-4600