Basic Information
| Provider Information | |||||||||
| NPI: | 1740650332 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAMARITAN VILLAGE HARLEM OUTPATIENT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 55 W 125TH ST | ||||||||
| Address2: | 11TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100274516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128644128 | ||||||||
| FaxNumber: | 2126629193 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 W 125TH ST | ||||||||
| Address2: | 11TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100274516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128644128 | ||||||||
| FaxNumber: | 2126629193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2015 | ||||||||
| LastUpdateDate: | 09/25/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CASEWORKER | ||||||||
| AuthorizedOfficialTelephone: | 2128644128 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAMARITAN VILLAGE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CASAC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | 31027 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.