Basic Information
Provider Information | |||||||||
NPI: | 1215465851 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ICL HEALTHCARE CHOICES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6209 16TH AVE | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112042702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7182340073 | ||||||||
FaxNumber: | 7182368456 | ||||||||
Practice Location | |||||||||
Address1: | 2110 BORDEN AVE | ||||||||
Address2: |   | ||||||||
City: | LONG ISLAND CITY | ||||||||
State: | NY | ||||||||
PostalCode: | 111014518 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7187845696 | ||||||||
FaxNumber: | 3476490663 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2017 | ||||||||
LastUpdateDate: | 06/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SIEBEL | ||||||||
AuthorizedOfficialFirstName: | MARIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7182340073 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 7001299R | NY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 33-1151 | 01 | NY | PART A | OTHER | G100253445 | 01 | NY | PART B | OTHER | 02186390 | 05 | NY |   | MEDICAID |