Healthcare Provider Details

I. General information

NPI: 1275760852
Provider Name (Legal Business Name): KYLE JAMES DITULLIO CASAC-T
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 06/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 2ND AVE
ALBANY NY
12202-1240
US

IV. Provider business mailing address

64 2ND AVE
ALBANY NY
12202-1240
US

V. Phone/Fax

Practice location:
  • Phone: 518-449-5170
  • Fax: 518-598-0493
Mailing address:
  • Phone: 518-449-5170
  • Fax: 518-598-0493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22400
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: