Healthcare Provider Details

I. General information

NPI: 1851239016
Provider Name (Legal Business Name): VICTOR TUCKER CASAC-T
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2026
Last Update Date: 03/21/2026
Certification Date: 03/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 BRIELLE AVE BLDG H
STATEN ISLAND NY
10314-6427
US

IV. Provider business mailing address

28 HOLLAND AVENUE
STATEN ISLAND NY
10303
US

V. Phone/Fax

Practice location:
  • Phone: 718-816-6589
  • Fax: 718-816-1868
Mailing address:
  • Phone: 646-474-4829
  • Fax: 646-474-4829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number41224
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: