Healthcare Provider Details

I. General information

NPI: 1215877873
Provider Name (Legal Business Name): RAWLE ANTHONY MCINTOSH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11440 VAN WYCK EXPY
SOUTH OZONE PARK NY
11420-2229
US

IV. Provider business mailing address

38 BUFFALO ST
ELMONT NY
11003-5015
US

V. Phone/Fax

Practice location:
  • Phone: 718-322-3455
  • Fax: 718-848-4152
Mailing address:
  • Phone: 516-666-6178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number41377
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: