Healthcare Provider Details

I. General information

NPI: 1205183191
Provider Name (Legal Business Name): HARLEM EAST LIFE PLAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2367-69 SECOND AVENUE
NEW YORK NY
10035
US

IV. Provider business mailing address

2367-69 SECOND AVENUE
NEW YORK NY
10035
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number72 083220
License Number StateNY

VIII. Authorized Official

Name: MR. BISHME ALLAH
Title or Position: THERAPIST
Credential: LMSW
Phone: 212-876-2300