Basic Information
| Provider Information | |||||||||
| NPI: | 1215184684 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ICL ACT TEAM BUSHWICK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 RECTOR ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100061705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123853030 | ||||||||
| FaxNumber: | 2123852380 | ||||||||
| Practice Location | |||||||||
| Address1: | 2384 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112333402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123853030 | ||||||||
| FaxNumber: | 2123852380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2008 | ||||||||
| LastUpdateDate: | 04/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | HOWARD | ||||||||
| AuthorizedOfficialFirstName: | DEWEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | C F O | ||||||||
| AuthorizedOfficialTelephone: | 2123853030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INSTITUTE FOR COMMUNITY LIVING, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 251B00000X | 7720470A | NY | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 01305004 | 05 | NY | MEDICAID |