Provider Demographics
NPI:1144619966
Name:FREEPORT PRIDE
Entity Type:Organization
Organization Name:FREEPORT PRIDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRION
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CASAC
Authorized Official - Phone:516-546-2822
Mailing Address - Street 1:500 COOPER CT
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-2108
Mailing Address - Country:US
Mailing Address - Phone:516-483-5772
Mailing Address - Fax:
Practice Address - Street 1:33 GUY LOMBARDO AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3637
Practice Address - Country:US
Practice Address - Phone:516-546-2822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161210916261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder