=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649481219
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTENSIVE CASE MANAGEMENT PROGRAM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2007
-----------------------------------------------------
Last Update Date | 10/17/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1841 BRENTWOOD RD
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11717-4625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-853-2762
-----------------------------------------------------
Fax | 631-853-2779
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1841 BRENTWOOD RD
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11717-4625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-853-2762
-----------------------------------------------------
Fax | 631-853-2779
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CASE MANAGER
-----------------------------------------------------
Name | DOREEN DESMOND
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 631-853-2762
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------