=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962840496
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | Y.M.C.A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2013
-----------------------------------------------------
Last Update Date | 06/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3911 RICHMOND AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10312-5110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-948-3232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3911 RICHMOND AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10312-5110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-948-3232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | MS. AMANDA WEXLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-948-3232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------