Provider Demographics
NPI:1255844460
Name:ALFRED, KENRICK (CASAC-T, CAMS II)
Entity Type:Individual
Prefix:MR
First Name:KENRICK
Middle Name:
Last Name:ALFRED
Suffix:
Gender:M
Credentials:CASAC-T, CAMS II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 JOHNSON AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-2690
Mailing Address - Country:US
Mailing Address - Phone:631-575-8062
Mailing Address - Fax:631-761-9475
Practice Address - Street 1:608 JOHNSON AVENUE
Practice Address - Street 2:SUITE 2
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703-1208
Practice Address - Country:US
Practice Address - Phone:631-575-8062
Practice Address - Fax:631-761-9475
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33671101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)