Healthcare Provider Details

I. General information

NPI: 1497706014
Provider Name (Legal Business Name): ALYSE FREDA-COLON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 E MAIN ST
CENTERPORT NY
11721-1541
US

IV. Provider business mailing address

15 WOODRUFF CT
HUNTINGTON NY
11743-2355
US

V. Phone/Fax

Practice location:
  • Phone: 516-635-4848
  • Fax:
Mailing address:
  • Phone: 631-271-0712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR048909-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: