Healthcare Provider Details

I. General information

NPI: 1740650332
Provider Name (Legal Business Name): SAMARITAN VILLAGE HARLEM OUTPATIENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2015
Last Update Date: 09/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 W 125TH ST 11TH FLOOR
NEW YORK NY
10027-4516
US

IV. Provider business mailing address

55 W 125TH ST 11TH FLOOR
NEW YORK NY
10027-4516
US

V. Phone/Fax

Practice location:
  • Phone: 212-864-4128
  • Fax: 212-662-9193
Mailing address:
  • Phone: 212-864-4128
  • Fax: 212-662-9193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number31027
License Number StateNY

VIII. Authorized Official

Name: SHARON JOHNSON
Title or Position: CASEWORKER
Credential: CASAC
Phone: 212-864-4128