Healthcare Provider Details

I. General information

NPI: 1609731082
Provider Name (Legal Business Name): STATEN ISLAND CENTER FOR INDEPENDENT LIVING INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 CASTLETON AVE
STATEN ISLAND NY
10301-2118
US

IV. Provider business mailing address

470 CASTLETON AVE
STATEN ISLAND NY
10301-2118
US

V. Phone/Fax

Practice location:
  • Phone: 718-720-9016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: JERRY ALLEN CARNEGIE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 213-952-9523