=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902054943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ICL-EAST NEW YORK PREVENTION-BASED SATELLITE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2008
-----------------------------------------------------
Last Update Date | 09/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 RECTOR ST FL 11
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10006-1705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-385-3030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 LINWOOD ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11208-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | C F O
-----------------------------------------------------
Name | MR. DEWEY HOWARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-385-3030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 7720101B
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------