Healthcare Provider Details

I. General information

NPI: 1053953570
Provider Name (Legal Business Name): TINA M JODIN CASAC T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2019
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CATHOLIC CHARITIES 27 MATTHEWS ST.
GOSHEN NY
10924
US

IV. Provider business mailing address

77 MERILINE AVENUE
NEW WINSOR NY
12553
US

V. Phone/Fax

Practice location:
  • Phone: 845-294-5124
  • Fax:
Mailing address:
  • Phone: 845-728-2586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number35345
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: