Provider Demographics
NPI:1134328784
Name:INSTITUTE FOR COMMUNITY LIVING, INC.
Entity Type:Organization
Organization Name:INSTITUTE FOR COMMUNITY LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:718-855-7485
Mailing Address - Street 1:8615 AVA PL
Mailing Address - Street 2:APT. 3G
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-2900
Mailing Address - Country:US
Mailing Address - Phone:718-855-7485
Mailing Address - Fax:718-855-1317
Practice Address - Street 1:INSTITUE FOR COMMUNITY LIVING, INC.
Practice Address - Street 2:40 RECTOR STREET
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006
Practice Address - Country:US
Practice Address - Phone:718-855-7485
Practice Address - Fax:718-855-1317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP06428611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty