Basic Information
| Provider Information | |||||||||
| NPI: | 1932252921 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INSTITUTE FOR COMMUNITY LIVING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2581 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112072412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184956700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2581 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112072412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184956700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ALBERTS | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ACTING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7184956700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | R057950-1 | NY | Y | Agencies | Community/Behavioral Health |
No ID Information.