Healthcare Provider Details

I. General information

NPI: 1053951038
Provider Name (Legal Business Name): RTA HTH INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2020
Last Update Date: 11/27/2023
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22001 JAMAICA AVE
QUEENS VILLAGE NY
11428-2140
US

IV. Provider business mailing address

22919 MERRICK BLVD # 541
LAURELTON NY
11413-2108
US

V. Phone/Fax

Practice location:
  • Phone: 718-412-1848
  • Fax:
Mailing address:
  • Phone: 718-412-1848
  • Fax: 718-977-0366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: KELLY A HOLMES
Title or Position: FOUNDER
Credential:
Phone: 718-412-1848