Healthcare Provider Details

I. General information

NPI: 1093305781
Provider Name (Legal Business Name): ALEXANDRA BRADY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17515 ROCKAWAY BLVD RM 365
JAMAICA NY
11434-5503
US

IV. Provider business mailing address

18 SMITH ST
GREENLAWN NY
11740-1220
US

V. Phone/Fax

Practice location:
  • Phone: 718-632-3275
  • Fax: 718-632-1568
Mailing address:
  • Phone: 631-355-2676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number33577
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: