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General NPI Number Information
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NPI Number | 1144619966
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Entity Type | Organization
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Legal Business Name | FREEPORT PRIDE
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Dates
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Enumeration Date | 01/16/2015
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Last Update Date | 01/16/2015
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Provider Practice Location Address
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Address Line | 33 GUY LOMBARDO AVE
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City | FREEPORT
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State | NY
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Zip | 11520-3637
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Country | US
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Telephone | 516-546-2822
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Fax |
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Provider Business Mailing Address
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Address Line | 500 COOPER CT
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City | UNIONDALE
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State | NY
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Zip | 11553-2108
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Country | US
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Telephone | 516-483-5772
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Fax |
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Authorized Official
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Title or Position | ASSISTANT DIRECTOR
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Name | MS. YOLANDA CARRION
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Credential | LCSW, CASAC
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Telephone | 516-546-2822
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 161210916
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License Number State | NY
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