Healthcare Provider Details

I. General information

NPI: 1649299694
Provider Name (Legal Business Name): RIVERDALE MENTAL HEALTH CLINIC-MICA PGRM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5676 RIVERDALE AVE SUITE 202
BRONX NY
10471-2138
US

IV. Provider business mailing address

5676 RIVERDALE AVE SUITE 202
BRONX NY
10471-2138
US

V. Phone/Fax

Practice location:
  • Phone: 718-796-5300
  • Fax:
Mailing address:
  • Phone: 718-796-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number6733100A
License Number StateNY

VIII. Authorized Official

Name: ROBERT BREWSTER
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 718-796-5300