MEDICARE: MR. EVERETT MILLER 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	21773	NY
2	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1841467776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EVERETT MILLER CASAC

Provider Business Mailing Address
First Line	:	3044 CONEY ISLAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-5660
Country	:	US
Telephone Number	:	718-265-4200
Fax Number	:

Provider Business Practice Location Address
First Line	:	3044 CONEY ISLAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-5660
Country	:	US
Telephone Number	:	718-265-4200
Fax Number	:

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

Provider Enumeration Date	:	05/09/2008
Last Update Date	:	01/30/2013

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