Healthcare Provider Details

I. General information

NPI: 1336532803
Provider Name (Legal Business Name): KENNETH SALLY CASAC-T
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 03/09/2015
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 Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number28611
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: