=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770835381
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATEN ISLAND MENTAL HEALTH SOCIETY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2012
-----------------------------------------------------
Last Update Date | 10/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 669 CASTLETON AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10301-2028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-442-2225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 669 CASTLETON AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10301-2028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-442-2225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HUMAN RESOURCE DIRECTOR
-----------------------------------------------------
Name | MS. MARY WALSH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-442-2226
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 087650
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------