Healthcare Provider Details

I. General information

NPI: 1821327495
Provider Name (Legal Business Name): KELVIN CANTEEN CASAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2369 2ND AVE
NEW YORK NY
10035-3108
US

IV. Provider business mailing address

2369 2ND AVE
NEW YORK NY
10035-3108
US

V. Phone/Fax

Practice location:
  • Phone: 212-876-2300
  • Fax: 212-722-7618
Mailing address:
  • Phone: 212-876-2300
  • Fax: 212-722-7618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17923
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: