Healthcare Provider Details

I. General information

NPI: 1215184684
Provider Name (Legal Business Name): ICL ACT TEAM BUSHWICK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2384 ATLANTIC AVE
BROOKLYN NY
11233-3402
US

IV. Provider business mailing address

40 RECTOR ST
NEW YORK NY
10006-1705
US

V. Phone/Fax

Practice location:
  • Phone: 212-385-3030
  • Fax: 212-385-2380
Mailing address:
  • Phone: 212-385-3030
  • Fax: 212-385-2380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number7720470A
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. DEWEY HOWARD
Title or Position: C F O
Credential:
Phone: 212-385-3030