Healthcare Provider Details

I. General information

NPI: 1710524541
Provider Name (Legal Business Name): THE LLEWELLYN J FORBES URBAN YOUTH INITIATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 LAFAYETTE AVE BXL SUITES
BRONX NY
10474-5331
US

IV. Provider business mailing address

PO BOX 601
BRONX NY
10465-0618
US

V. Phone/Fax

Practice location:
  • Phone: 646-302-4426
  • Fax:
Mailing address:
  • Phone: 646-302-4426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: LLEWELLYN FORBES
Title or Position: EXECUTIVE DIRECTOR
Credential: ED. M
Phone: 646-302-4426