Healthcare Provider Details

I. General information

NPI: 1104158435
Provider Name (Legal Business Name): SIBY CHACKO LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 02/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E 149TH ST
BRONX NY
10451-5504
US

IV. Provider business mailing address

234 E 149TH ST
BRONX NY
10451-5504
US

V. Phone/Fax

Practice location:
  • Phone: 718-579-5000
  • Fax: 718-579-5310
Mailing address:
  • Phone: 718-579-5000
  • Fax: 718-579-5310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number072260
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: