Basic Information
| Provider Information | |||||||||
| NPI: | 1548405392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRAGOSO | ||||||||
| FirstName: | RALPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1156 N BROADWAY | ||||||||
| Address2: | |||||||||
| City: | YONKERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 107011108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149653700 | ||||||||
| FaxNumber: | 9149653883 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 DAYTON LN STE 205 | ||||||||
| Address2: | |||||||||
| City: | PEEKSKILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105662860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147363371 | ||||||||
| FaxNumber: | 9147363372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2008 | ||||||||
| LastUpdateDate: | 12/09/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 00355940 | 01 | NY | AGENCY MEDICAID PROVIDER ID | OTHER | WVE061 | 01 | NY | AGENCY MEDICARE ID# | OTHER | 1285628552 | 01 | NY | AGENCY NPI # | OTHER |