Healthcare Provider Details

I. General information

NPI: 1770529026
Provider Name (Legal Business Name): BANG AWARENESS ALCOHOL PREVENTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 UNIVERSITY AVE STADIUM STATION 524525
BRONX NY
10452
US

IV. Provider business mailing address

1138 E 229TH ST DRIVE SOUTH AVE 6G
BRONX NY
10466
US

V. Phone/Fax

Practice location:
  • Phone: 347-220-7578
  • Fax:
Mailing address:
  • Phone: 917-239-5729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number5292
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberI069
License Number StateNY

VIII. Authorized Official

Name: PROF. MARITZA MCCONNEGHEY
Title or Position: CHIEF EXEC OFFICER
Credential: HHS LPN
Phone: 917-239-5729