Healthcare Provider Details

I. General information

NPI: 1265098024
Provider Name (Legal Business Name): ALYSSA-RAY LEON BOUMAN NYS CASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ROUTE 59 STE 117
AIRMONT NY
10901-4927
US

IV. Provider business mailing address

100 ROUTE 59 STE 117
AIRMONT NY
10901-4927
US

V. Phone/Fax

Practice location:
  • Phone: 453-699-7018
  • Fax:
Mailing address:
  • Phone: 845-369-9701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number31918
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: