MEDICARE: RADIANT SELF THERAPY LLC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1902441504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADIANT SELF THERAPY LLC

Provider Business Mailing Address
First Line	:	68 HAUSMAN ST APT 3
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11222-7111
Country	:	US
Telephone Number	:	860-810-0371
Fax Number	:

Provider Business Practice Location Address
First Line	:	68 HAUSMAN ST APT 3
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11222-7111
Country	:	US
Telephone Number	:	860-810-0371
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KATHERINE VOLLONO
Credential	:
Telephone Number	:	860-810-0371

Provider Enumeration Date	:	11/07/2019
Last Update Date	:	11/07/2019

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