Healthcare Provider Details

I. General information

NPI: 1558667600
Provider Name (Legal Business Name): PLAINVIEW OLD BETHPAGE YOUTH ACTIVITIES COUNCIL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2011
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 TERMINAL DR STE. 3
PLAINVIEW NY
11803-2318
US

IV. Provider business mailing address

202 TERMINAL DR SUITE 3
PLAINVIEW NY
11803-2318
US

V. Phone/Fax

Practice location:
  • Phone: 516-576-3120
  • Fax: 516-576-3446
Mailing address:
  • Phone: 516-576-6120
  • Fax: 516-576-3446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number070611542
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02861145
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: MELANIE CONWAY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 516-576-3120