Basic Information
| Provider Information | |||||||||
| NPI: | 1548623424 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 25 CHAPEL STREET | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 W 130TH ST | ||||||||
| Address2: | APT 3C | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100271813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6465423980 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25 CHAPEL ST | ||||||||
| Address2: | SUITE 901 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112011952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183980153 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2016 | ||||||||
| LastUpdateDate: | 03/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | BLAKE | ||||||||
| AuthorizedOfficialFirstName: | LORIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7183980153 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | 094063 | NY | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.