Basic Information
| Provider Information | |||||||||
| NPI: | 1740739721 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ICL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3547 NOSTRAND AVE APT 2E | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112295231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3472496918 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25 CHAPEL ST FL 9 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112011954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188757510 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2016 | ||||||||
| LastUpdateDate: | 10/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3472496918 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.