MEDICARE: KENNETH PFEIFFER CASAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	18708	NY

General Provider Information

NPI Number	:	1255859096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH PFEIFFER CASAC

Provider Business Mailing Address
First Line	:	198 BEACH 102ND ST APT 1E
Second Line	:
City	:	ROCKAWAY PARK
State	:	NY
Zip	:	11694-2853
Country	:	US
Telephone Number	:	347-205-1780
Fax Number	:

Provider Business Practice Location Address
First Line	:	830 FOREST AVE RM 139
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10456-7802
Country	:	US
Telephone Number	:	718-742-5684
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2017
Last Update Date	:	09/27/2024

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