=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780740795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY AND CONSULTING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 UTICA AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11213-2339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-771-3136
-----------------------------------------------------
Fax | 718-773-4273
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 124 UTICA AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11213-2339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-771-3136
-----------------------------------------------------
Fax | 718-773-4273
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JOHN SAMUEL
-----------------------------------------------------
Credential | RLCSW
-----------------------------------------------------
Telephone | 718-771-3136
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | PR039834-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------