Basic Information
| Provider Information | |||||||||
| NPI: | 1295868271 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GUIDANCE CENTER OF BROOKLYN, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 BROAD ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100042400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123853030 | ||||||||
| FaxNumber: | 2126197275 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 CHAPEL ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112011952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188757510 | ||||||||
| FaxNumber: | 7188588410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | BACCHUS | ||||||||
| AuthorizedOfficialFirstName: | LYNETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSIST CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2123853030 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | BA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 6965001A | NY | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 00245065 | 05 | NY | MEDICAID |