Provider Demographics
NPI:1215184684
Name:ICL ACT TEAM BUSHWICK
Entity Type:Organization
Organization Name:ICL ACT TEAM BUSHWICK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C F O
Authorized Official - Prefix:MR
Authorized Official - First Name:DEWEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-385-3030
Mailing Address - Street 1:40 RECTOR ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10006-1705
Mailing Address - Country:US
Mailing Address - Phone:212-385-3030
Mailing Address - Fax:212-385-2380
Practice Address - Street 1:2384 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11233-3402
Practice Address - Country:US
Practice Address - Phone:212-385-3030
Practice Address - Fax:212-385-2380
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INSTITUTE FOR COMMUNITY LIVING, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-27
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7720470A251B00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01305004Medicaid