Healthcare Provider Details

I. General information

NPI: 1528232220
Provider Name (Legal Business Name): CLEVELAND SHELTON JOSEPH CASAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4360 FURMAN AVE APT 4H
BRONX NY
10466-1544
US

IV. Provider business mailing address

4360 FURMAN AVE APT 4H
BRONX NY
10466-1544
US

V. Phone/Fax

Practice location:
  • Phone: 347-346-9278
  • Fax: 347-346-9278
Mailing address:
  • Phone: 347-346-9278
  • Fax: 347-346-9278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number101777
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: