Healthcare Provider Details

I. General information

NPI: 1720696537
Provider Name (Legal Business Name): KYRON STEVENSON CASAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2020
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
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

4442 ARTHUR KILL RD STE 4
STATEN ISLAND NY
10309-1321
US

V. Phone/Fax

Practice location:
  • Phone: 718-816-6589
  • Fax:
Mailing address:
  • Phone: 718-356-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: