Healthcare Provider Details

I. General information

NPI: 1073370284
Provider Name (Legal Business Name): CARLO DELACRUZ BASCONCILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2857 LINDEN BLVD
BROOKLYN NY
11208-5126
US

IV. Provider business mailing address

9229 245TH ST
FLORAL PARK NY
11001-3916
US

V. Phone/Fax

Practice location:
  • Phone: 718-235-3100
  • Fax: 718-277-0822
Mailing address:
  • Phone: 516-493-0721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: