Basic Information
| Provider Information | |||||||||
| NPI: | 1396812780 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOSE | ||||||||
| FirstName: | KURUVILLA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOSEPH | ||||||||
| OtherFirstName: | KURUVILLA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 381 WHIPPLE ST | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117172845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314350789 | ||||||||
| FaxNumber: | 6317981845 | ||||||||
| Practice Location | |||||||||
| Address1: | 445 OAK ST | ||||||||
| Address2: | |||||||||
| City: | COPIAGUE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117263111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316917080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 037884-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.