Healthcare Provider Details

I. General information

NPI: 1659862738
Provider Name (Legal Business Name): JEFFREY KIEWHON CANADY CASAC-T
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1369 BROADWAY
NEW YORK NY
10018-7200
US

IV. Provider business mailing address

2698 8TH AVE
NEW YORK NY
10030-1219
US

V. Phone/Fax

Practice location:
  • Phone: 212-268-8830
  • Fax: 212-947-2424
Mailing address:
  • Phone: 347-583-0718
  • Fax: 212-947-2424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number34585
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: