Healthcare Provider Details

I. General information

NPI: 1437544186
Provider Name (Legal Business Name): CRAIG WILLIAMS CASAC-T
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 03/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2976 NORTHERN BLVD
LONG ISLAND CITY NY
11101-2822
US

IV. Provider business mailing address

2976 NORTHERN BLVD
LONG ISLAND CITY NY
11101-2822
US

V. Phone/Fax

Practice location:
  • Phone: 212-690-6202
  • Fax: 212-690-2757
Mailing address:
  • Phone: 212-690-6202
  • Fax: 212-690-2757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number06287
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01523
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: