Healthcare Provider Details

I. General information

NPI: 1396053203
Provider Name (Legal Business Name): STEPHANIE L URBAN CASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 09/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 GLENMORE AVENUE
CENTRAL ISLIP NY
11722
US

IV. Provider business mailing address

115 GLENMORE AVENUE
CENTRAL ISLIP NY
11722
US

V. Phone/Fax

Practice location:
  • Phone: 631-647-3100
  • Fax: 631-647-2058
Mailing address:
  • Phone: 631-647-3100
  • Fax: 631-647-2058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22035
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: