=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114726916
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALCHEMICAL KINNECTIONS INTEGRATIVE THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2025
-----------------------------------------------------
Last Update Date | 05/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 FRANK E RODGERS BLVD S
-----------------------------------------------------
City | HARRISON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07029-2085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-352-2098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 TOWN SQUARE PL STE 1238
-----------------------------------------------------
City | JERSEY CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07310-1810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-352-2098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER / CEO
-----------------------------------------------------
Name | SURRAINE BASCOME
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 929-352-2098
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------