Healthcare Provider Details

I. General information

NPI: 1184106957
Provider Name (Legal Business Name): INTEGRATIVE THERAPY FOR CHILDREN AND ADOLESCENTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 W MARKET ST STE 3B
RED HOOK NY
12571-1510
US

IV. Provider business mailing address

35 W MARKET ST STE 3B
RED HOOK NY
12571-1510
US

V. Phone/Fax

Practice location:
  • Phone: 914-670-1376
  • Fax:
Mailing address:
  • Phone: 914-670-1376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number087203
License Number StateNY

VIII. Authorized Official

Name: REBECCA LEWIS
Title or Position: LCSW
Credential: LCSW, RPT
Phone: 914-670-1376