Healthcare Provider Details

I. General information

NPI: 1275683732
Provider Name (Legal Business Name): KEITH MICHAEL BRACKETT LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 AMSTERDAM AVE
NEW YORK NY
10031-4611
US

IV. Provider business mailing address

3067 33RD ST APT 2A
ASTORIA NY
11102-1437
US

V. Phone/Fax

Practice location:
  • Phone: 212-694-9200
  • Fax: 212-368-5608
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0752351
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: