Healthcare Provider Details

I. General information

NPI: 1700749470
Provider Name (Legal Business Name): MALIK RAYMOND MILLER CASAC-T
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1614 WEIRFIELD ST
RIDGEWOOD NY
11385-5350
US

IV. Provider business mailing address

30 SEAMAN AVE APT 3M
NEW YORK NY
10034-6312
US

V. Phone/Fax

Practice location:
  • Phone: 718-456-7820
  • Fax:
Mailing address:
  • Phone: 914-863-4048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number41037
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: