Healthcare Provider Details

I. General information

NPI: 1114304458
Provider Name (Legal Business Name): SUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 E 107TH ST
NEW YORK NY
10029-3905
US

IV. Provider business mailing address

170 E 107TH ST
NEW YORK NY
10029-3905
US

V. Phone/Fax

Practice location:
  • Phone: 212-722-7507
  • Fax: 212-722-7583
Mailing address:
  • Phone: 212-722-7507
  • Fax: 212-722-7583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number150511551
License Number StateNY

VIII. Authorized Official

Name: LAURA WIERBICKI
Title or Position: PROGRAM MANAGER
Credential: LMSW
Phone: 212-722-7507