Healthcare Provider Details

I. General information

NPI: 1942359476
Provider Name (Legal Business Name): CAMELOT OF STATEN ISLAND, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 PORT RICHMOND AVENUE
STATEN ISLAND NY
10302
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 718-981-8117
  • Fax: 718-981-8309
Mailing address:
  • Phone: 718-356-5100
  • Fax: 718-981-8309

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: MR. LUKE J. NASTA
Title or Position: EXECUTIVE DIRECTOR
Credential: MPA, CASAC
Phone: 718-356-5100