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General NPI Number Information
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NPI Number | 1245785005
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Entity Type | Organization
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Legal Business Name | HISPANIC THERAPY SERVICE
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Dates
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Enumeration Date | 08/22/2016
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Last Update Date | 08/22/2016
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Provider Practice Location Address
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Address Line | 26 ROOSEVELT CT
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City | WESTBURY
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State | NY
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Zip | 11590-4135
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Country | US
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Telephone | 917-755-2425
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Fax |
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Provider Business Mailing Address
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Address Line | 26 ROOSEVELT CT
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City | WESTBURY
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State | NY
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Zip | 11590-4135
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Country | US
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Telephone | 917-755-2425
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Fax |
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Authorized Official
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Title or Position | PSYCHOTHERAPIST
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Name | MR. RAFAEL ERIC BOU
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Credential | L.C.S.W.
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Telephone | 917-755-2425
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 081037-1
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License Number State | NY
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