Provider Demographics
NPI:1477707289
Name:DE LA GARZA, CONRADO
Entity Type:Individual
Prefix:
First Name:CONRADO
Middle Name:
Last Name:DE LA GARZA
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 1:11 FARBER DR
Mailing Address - Street 2:UNIT D
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-1500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 FARBER DR
Practice Address - Street 2:UNIT D
Practice Address - City:BELLPORT
Practice Address - State:NY
Practice Address - Zip Code:11713-1500
Practice Address - Country:US
Practice Address - Phone:631-286-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22725101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)