Provider Demographics
NPI:1073370284
Name:BASCONCILLO, CARLO DELACRUZ
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:DELACRUZ
Last Name:BASCONCILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9229 245TH ST
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-3916
Mailing Address - Country:US
Mailing Address - Phone:516-493-0721
Mailing Address - Fax:
Practice Address - Street 1:2857 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-5126
Practice Address - Country:US
Practice Address - Phone:718-235-3100
Practice Address - Fax:718-277-0822
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health