Healthcare Provider Details

I. General information

NPI: 1649794629
Provider Name (Legal Business Name): FACES NY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 08/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 W 116TH ST
NEW YORK NY
10026-2679
US

IV. Provider business mailing address

114 W 116TH ST
NEW YORK NY
10026-2679
US

V. Phone/Fax

Practice location:
  • Phone: 212-865-0960
  • Fax: 212-663-4310
Mailing address:
  • Phone: 212-865-0960
  • Fax: 212-663-4310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number085451
License Number StateNY

VIII. Authorized Official

Name: MR. KEITH DOUGLAS BLACKBURN
Title or Position: CLINICAL SUPERVISOR
Credential: LCSW
Phone: 212-865-0960