Healthcare Provider Details

I. General information

NPI: 1982912929
Provider Name (Legal Business Name): CLUB MENTAL HEALTH COUNSELING SERVICES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 ADA DR
STATEN ISLAND NY
10314-1434
US

IV. Provider business mailing address

PO BOX 140695
STATEN ISLAND NY
10314-0695
US

V. Phone/Fax

Practice location:
  • Phone: 718-873-3189
  • Fax: 718-982-8508
Mailing address:
  • Phone: 781-873-3189
  • Fax: 718-982-8508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001024-1
License Number StateNY

VIII. Authorized Official

Name: MS. LESLIE B MARTIN
Title or Position: PRESIDENT
Credential: LMHC
Phone: 718-873-3189