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General NPI Number Information
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NPI Number | 1982912929
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Entity Type | Organization
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Legal Business Name | CLUB MENTAL HEALTH COUNSELING SERVICES, P.C.
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Dates
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Enumeration Date | 09/23/2010
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Last Update Date | 09/23/2010
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Provider Practice Location Address
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Address Line | 272 ADA DR
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City | STATEN ISLAND
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State | NY
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Zip | 10314-1434
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Country | US
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Telephone | 718-873-3189
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Fax | 718-982-8508
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Provider Business Mailing Address
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Address Line | PO BOX 140695
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City | STATEN ISLAND
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State | NY
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Zip | 10314-0695
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Country | US
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Telephone | 781-873-3189
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Fax | 718-982-8508
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. LESLIE B MARTIN
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Credential | LMHC
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Telephone | 718-873-3189
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 001024-1
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License Number State | NY
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